Appeals & Grievances Coordinator

Mass General Brigham•Somerville, MA

22h•$30 - $44•Remote

About The Position

The Appeals and Grievance Coordinator will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all our product offerings (Commercial, Medicaid and Medicare). This role will be responsible for documenting and guiding 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 collaborators 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. The Grievance and Appeals Coordinator will also present cases to the Appeals Committee. Detailed knowledge of all applicable health plan policies and procedures, MassHealth, the Health Connector, DOI regulations, Medicare regulations and Commercial product contractual obligations is a key element of this role. Strong customer service and interpersonal skills during regular interactions with customers, providers, and external agencies.

Requirements

Bachelor's Degree Related Field of Study preferred
Health plan experience, ideally within customer service, quality or appeals and grievances area. 3-5 years required
Superior verbal and written communication skills.
Understanding of health plan operations, ideally in customer service and/or appeals and grievances.
Proficient in Microsoft Excel and Word.
Sensitive to confidential materials and the ability to maintain a professional demeanor in potentially difficult situations involving providers, members, and internal customers.
Able to understand and adhere to sophisticated regulations.
Demonstrate Mass General Brigham Health Plans core brand principles of always listening, challenging conventions, and providing value.
Bring fresh ideas forward by listening to and working with employees and the people we serve.
Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
Strong, demonstrated track record of an ability to complete time, on budget, and on scope.
Strong skills for technology-based solutions.
Ability to inject energy, when and where it’s needed.
Current in healthcare trends.
Proven forward, transformational thinking; ability to see “what is” and envision “what could be.”
Ability to develop, introduce, defend, and gain support for new insights and approaches.
Excellent leadership skills and leadership track record.
Ability to translate and communicate sophisticated topics in a variety of forums, tailoring communications to optimally fit and influence the targeted audience, strong executive presence, presentation, and communication skills.
Strong verbal, active listening, and written communication skills required.
Ability to view the long-range trends and cycles of the business and industry and see the “big picture.”
Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
Ability to challenge the status quo and drive innovative thinking and the capability to efficiently implement strategy.
Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
Unquestionable integrity.

Responsibilities

Coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all our product offerings (Commercial, Medicaid and Medicare).
Document and guide the life cycle of all member appeals and grievances and provider appeals.
Maintain tracking information.
Work closely with internal and external collaborators to quickly resolve cases.
Communicate orally and in writing to all involved parties during the appeals and grievances process.
Compile reports for analysis purposes.
Present cases to the Appeals Committee.

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