Appeals & Grievances Coordinator

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

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. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.The Appeals Coordinator will coordinate, process, investigate, and document all aspects of member complaints across our Medicare line of business. This role will be responsible for documenting and guiding the life cycle of all member appeals. This includes, but is not limited to, maintaining tracking information, working closely with internal stakeholders and external vendors/partners to quickly resolve cases, communicating orally and/or in writing to all involved parties during the grievances process, and documenting according to established standards for reporting and analysis purposes.The Appeals Coordinator must have detailed knowledge of all applicable health plan policies and procedures. Regulatory (CMS, DOI, MassHealth) and contractual requirements knowledge and expertise are key elements of this role. Strong customer service and interpersonal skills are mandatory during regular interactions with customers, providers, and external agencies.Principal Duties and Responsibilities:

• * Handle a large volume of incoming appeals (both formal and informal) from receipt through resolution, ensuring that all grievances are resolved within contractual and regulatory timeframes. Ensure accurate time management of all work, ensuring results are met on time with high-quality standards
• * Document and supervise all grievances in the appropriate tracking systems, ensuring the highest quality and accuracy of work.
• * Ensure grievance files are complete and contain all relevant documentation, including research materials, acknowledgment and resolution letters, and any other pertinent information related to the case.
• * Collaborate with key departments on all grievances, including Compliance, Pharmacy, Medical Directors, Sales, and other relevant senior and executive staff.
• * Assists with or is lead on external appeal investigation from regulatory agencies, including CMS, EOHHS, and the Division of Insurance
• * Assists with preparing formal written responses to external regulators
• * Work independently with members on their grievances. Provide effective and appropriate information on an ongoing basis to members as you resolve their issues.
• * Aid in the preparation of reports to various collaborators and provide feedback on ways in which reporting can be enhanced and improved.
• * Stay ahead of any changes to health plan policies and procedures and work closely with key partners on ensuring that the files being prepared for external agencies are accurate, well-written, and meet the needs of all parties. Participate in team meetings and other development work, ensuring that information is presented accurately and your contribution to any development projects is notable.
• * Participate in internal and external audits and be receptive to any feedback and training being offered.
• * Ability to function and excel in a remote environment, handling time-critical appeals and grievance cases.
• * Hold self and others accountable to meet commitments.
• * Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• * Build positive relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• * Other duties as assigned with or without accommodation.

  Qualifications

  Education

  • High School Diploma required; Bachelor's Degree preferred

  Experience

  • At least 3-5 years of health plan experience, ideally within customer service, quality, or appeals and grievances areas preferred
  • Experience leading appeals and grievances for Medicare products and plans is highly preferred
  • Bilingual a plus

  Knowledge, Skills, and Abilities

  • Strong aptitude for technology-based solutions.
  • Strong customer service skills.
  • Excellent communication skills.
  • Ability to adapt to changing priorities and work effectively in a dynamic environment.
  • Excellent organizational abilities to manage multiple tasks, prioritize work, and meet deadlines.

  Additional Job Details (if applicable)

  Working Conditions

  • This is a remote role that can be done from most US states
  • This is a full-time role with a Tuesday through Saturday schedule, 8:30 AM - 5:00 PM EST
  • This role includes a rotating holiday coverage requirement; holidays are shared among team members on a scheduled rotation

  Remote Type

  Remote

  Work Location

  399 Revolution Drive

  Scheduled Weekly Hours

  40

  Employee Type

  Regular

  Work Shift

  Day (United States of America)

  Pay Range

  $30.60 - $44.51/Hourly

  Grade

  6At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors.
• The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

  EEO Statement:

  8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

  Mass General Brigham Competency Framework

  At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.