This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA.

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

The Professional Medical Letter Writer is responsible for independent auditing, editing, composing, and processing adverse determination letters, providing timely notifications to providers of denials for the Utilization Management Care Management Department. The incumbent is also responsible for ensuring that letters are generated and mailed with the required attachments and that the authorizations are updated appropriately, and processed in a timely, accurate manner in compliance with performance standards regarding denial letter turnaround time and quality. Additionally, the incumbent will assist in various Utilization Management Care Management projects and provider outreach initiatives, with the generation of reports and other projects and duties as assigned.

ESSENTIAL FUNCTIONS
The successful candidate will have proficient written and verbal communication skills, demonstrating a mastery of English including medical terminology. In addition, this incumbent must possess a strong understanding of utilization management and adverse determination regulations and processes. The Professional Letter Writer must ensure grammar and formatting are correct using plain language to clearly communicate adverse decisions to members and providers. As well, this candidate must demonstrate excellent computer skills.

Core competencies:
* Letter writing experience required
* Expertise in Medical Terminology
* Proficient with English composition and grammar
* Ability to follow directions and work independently
* Proficient with Microsoft Word, Excel, Outlook, SharePoint, PC-based operating systems, and web-based phone system
* Excellent communication skills; verbal, written, and interpersonal skills
* Ability to efficiently prioritize and organize work
* Keen attention to detail, analytical problem solver
* Ability to be creative and develop solutions to problems with a demonstrated use of critical thinking skills
* Strong internal and external customer focus

Core Functions:
* Proofread, edit, and compose adverse determination letters based on written decisions by the secondary reviewer, using plain language, following regulations, policies, and procedures
* Correspond with external and internal customers for the purpose of notification of an authorization decision following the department/company policies and procedures
* Review and investigate a variety of member and provider correspondence to ensure all elements of the letter match what is in the Clinical system (QNXT) and ensure the correct template and attributes are being used
* Ensure member and provider determination letters generate and set to mail with proper attachments following state regulations and/or plan contract guidelines and turn-around-times
* Coordinate the reprint and deletion process for any determination letters that had updates applied
* Communicate and collaborate with colleagues to identify and address unique circumstances and/or potential errors regarding the written decision and/or the overall process as needed
* Identify non-compliant determination letters and communicate to leadership team for immediate investigation and resolution
* Identify potential erroneous adverse determinations and communicate to leadership team for investigation and resolution
* Identify deficiencies and provide feedback to proper stakeholder to reduce errors and improve processes and performance to ensure quality
* Coordinate peer-to-peer reviews with external providers and internal medical directors following the process
* Participate in inter-departmental meetings and training as required
* Maintain departmental process documents
* Other duties as assigned with or without accommodation

WORKING CONDITIONS AND PHYSICAL EFFORT
* Able to stand and sit for periods of time as needed to perform work-related functions
* Ability to use a laptop/computer, manual dexterity, headset use
* Lift up to 25 lbs
* Work is performed in a remote setting but may require travel to an in-office location if technical difficulties inhibit job performance or as required for meetings

KNOWLEDGE AND EDUCATION

* BA in English- Preferred
* LPN preferred. Medical Assistant considered.

EXPERIENCE

Required:
* Experience with letter writing in a managed care setting
* Knowledge of utilization management process (i.e. Health Center, Hospital, Insurance Company, Physician office)
* Knowledge of Utilization Management regulations and standards

:
SKILLS/COMPETENCIES

* Demonstrates Mass General Brigham Health Plan's Core Values of Accountability, Service Excellence, Quality Care, Diversity, and forging strong relationships
* Respect the talent and unique contribution of every individual, culture, and ethnic group, and treat all people in a fair and equitable manner
* Exercise self-awareness; monitor impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback
* Accountable for delivering high-quality work, and acting with a clear sense of ownership
* Mature disposition with a positive outlook

OTHER SKILLS

* Bilingual language skills desirable

Proficiency with composing adverse determination letters and mailing them to providers and members without any oversite with escalations to leadership when quality, timeliness, and standards are not met. The next step for this incumbent is to identify process improvement techniques within the letter-writing workflow following timeliness and quality regulations/procedures.

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.