Duals Supervisor, Appeals and Grievances

Mass General Brigham•Somerville, MA

5d•$78,000 - $113,454•Remote

About The Position

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 The Duals Supervisor, Appeals and Grievances provides day-to-day supervision of a team of 4-6 appeals and grievance coordinators and is ultimately responsible for the work product of this team and the Duals line of business. The Supervisor oversees all aspects of the Appeal and Grievance processes in accordance with the Massachusetts Division of Insurance and Executive Office of Health and Human Services (EOHHS) requirements, the Centers for Medicare and Medicaid Services (CMS), as well as the National Committee on Quality Assurance (NCQA) guidelines. The Supervisor will lead the efforts to coordinate daily operations, which include identifying/communicating any areas of risk and achieving maximum efficiency across all appeal and grievance processes. The Supervisor collaborates with the Sr. Manager, Appeals and Grievances, as well as other senior and executive staff, to ensure optimum performance within the Appeals and Grievances Department, while ensuring compliance with all applicable performance standards and regulatory, contractual, and corporate policies and procedures. The Supervisor will be expected to work closely with the leadership to identify industry-standard operational metric measure and compare benchmarks to individual and departmental performance. The Supervisor will be responsible for presenting metrics to leadership and proposing any solutions to identified areas of opportunity. In addition to supervising the day-to-day activities of the Appeals and Grievance Department, the Supervisor is an active, visible participant on many cross-functional teams that address strategic and business projects such as cost savings measures, infrastructure efficiencies, regulatory and contractual requirements, and break/fixes.

Requirements

Bachelor’s degree required or the equivalent combination of training and experience.
At least 5-7 years of health plan operations/appeals and grievance experience required
At least 2-3 years' experience with Medicare and/or Dual Special Needs Programs operations
At least 3 years of experience managing and training staff, ideally within an appeals and grievances department, whether in a formal or informal capacity required.
Experience representing and solving the needs of staff including executive staff.
Experience setting up appeals and grievances workflows across new products and plans.

Nice To Haves

Advanced degree such as a master's or RN preferred

Responsibilities

Facilitates regular bi-weekly one-on-one meetings and weekly team staff meetings with the Appeals and Grievances department.
Identifies the training needs of the coordinators and works with key stakeholders, including the Learning and Development Dept, Customer Service, Product, etc., to develop training guides and curriculum
Provide real- time oversight and education to the staff to ensure they are meeting their goals related to the intake, triaging, coordination, and documentation of all appeals and grievances
Collaborates with the auditing team to identify and maintain quality control processes that ensure all standards for timely acknowledgment, resolution, and documentation standards are met consistently.
Represents the Appeals and Grievances Dept where cases are discussed and follow-up steps are identified; ensure the requirements of various organizations (NCQA, CMS, etc.) are represented.
Ensure timely appeal and grievance reporting to leadership for dissemination to regulatory agencies and contracted clients.
Collaborate with internal departments as necessary (Customer Service Center, Provider Network, Claims, Utilization Management, Pharmacy) to ensure the timely resolution of all appeals and grievances.
Meet regularly with internal customers to identify process improvement opportunities.
Collaborates with leadership on appeal and grievance reports and analysis to various internal stakeholders including, but not limited to, the Quality Improvement Committee, the Utilization Management Committee, and the Audit and Compliance Commit
Chair the Appeal Subcommittee and recommend cases for full review at the larger Appeals Committee.
Collaborates with the leadership on all NCQA matters relating to appeals and grievances.
Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
Escalates issues to the senior leadership as needed.
Hold self and others accountable to meet commitments.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
Other duties as assigned with or without accommodation.