Appeals & Grievances Coordinator
About The Position
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 The incumbent will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all of our product offerings (Commercial, Medicaid and Medicare). Responsible for documenting and owning the life cycle of all member appeals and grievances and provider appeals. This includes but is not limited to maintaining tracking information, working closely with internal and external stakeholders to quickly resolve cases, communicating orally and in writing to all involved parties during the appeals and grievances process and compiling reports for analysis purposes.
Requirements
- Bachelor's Degree Related Field of Study preferred
- Can this role accept experience in lieu of a degree? yes
- At least 3-5 years of health plan experience, ideally within customer service, quality or appeals and grievances area
- 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.
Responsibilities
- Handle a large volume of incoming grievances and appeals from receipt through resolution, ensuring that all appeals are resolved within contractual timeframes.
- Document and track all appeals and grievances in the appropriate tracking systems, ensuring the quality and accuracy of work is exemplary.
- Ensure appeal and 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.
- Assist in the preparation of reports to various stakeholders, whether they are member appeals and grievances, or provider appeals; provide feedback on ways in which reporting can be enhanced and improved.
- Prepare files for external review when informed of an external hearing.
- Work independently with members on their appeals, which can include administrative appeals, clinical appeals, and pharmacy appeals, as well as their grievances. Provide helpful and appropriate information on an ongoing basis to members as you resolve their issue.
- Resolves payment issues, claims processing issues, and identifies system improvements which in turn will reduce provider appeals.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Number of Employees
5,001-10,000 employees
