Member Appeals and Grievances Coordinator
About The Position
The Member Appeals and Grievances (A&G) Coordinator performs administrative functions for incoming member appeals and grievances, including identification, intake, and distribution. The Coordinator maintains organized, secure, and efficient record-keeping processes and responds to members, providers, and other business areas about case status and A&G processes in a timely, professional manner. The role also builds collaborative relationships across departments. This full-time remote position reports to a supervisor who provides direct supervision weekly. It has no supervisory responsibilities. The role normally takes place in a typical interior/office work environment, with little or no physical effort and little or no exposure to physical risk. Regular, reliable attendance is essential, and some evening or weekend hours may be necessary. WellSense Health Plan is a nonprofit health insurer serving more than 740,000 members across Massachusetts and New Hampshire. The listed compensation range is $20.19–$28.13, based on Boston-area data and subject to geographic adjustment. The position includes benefits such as medical, dental, vision, and pharmacy coverage; merit increases; Flexible Spending Accounts; 403(b) savings matches; paid time off; career advancement opportunities; and resources supporting employee and family wellbeing.
Requirements
- Bachelor’s degree in Health Care Administration or a related field, or an equivalent combination of education, training, and experience.
- Experience with Microsoft Office applications.
- Demonstrated ability to use proprietary healthcare management systems.
- Ability to identify problems and procedural irregularities, collect data, establish facts, and draw valid conclusions.
- Excellent attention to detail and organizational skills.
- Excellent oral, written, and interpersonal communication skills.
- Ability to work flexibly and independently and collaborate with other departments across the organization.
- Ability to work effectively in a fast-paced environment.
- Problem-solving ability.
- Ability to abstract data, analyze it, and identify trends.
- Ability to multitask.
- Ability to provide high-quality customer service.
- Ability to work some evening or weekend hours if necessary.
- Successful completion of a pre-employment background check.
Nice To Haves
- Experience with JIVA.
- Experience with Facets.
- Experience with Express Scripts, Inc.
- Experience with HPMS.
- Experience with Access.
- Two or more years of experience in a healthcare setting, specifically related to Appeals and Grievances.
- Experience with data entry, trend analysis, and reporting.
- Experience with health insurance, including Commercial, Medicaid, and Medicare.
- Experience with rules and regulations governing Commercial, Medicaid, and Medicare health insurance.
- Experience communicating with a provider network.
- Certified Professional Coder (CPC) certification.
Responsibilities
- Identify appeals and grievances appropriately and compliantly during intake, enter them accurately and in detail into the A&G system of record, and distribute them to Appeals and Grievances Specialists according to department rules and deadlines.
- Maintain data accuracy and develop or manage workflows that minimize manual errors and support compliance, consistency, trend analysis, reporting, and data integrity.
- Identify trends or areas of concern and raise them to the A&G Management team.
- Assist the A&G Management team with audits and reporting needs as necessary and applicable.
- Participate in or create daily, weekly, and/or monthly reports for internal auditing and monitoring, including analysis and trend identification.
- Participate in or lead training for the A&G Management team, A&G Specialists, and/or new Coordinator staff, and maintain current materials related to the Coordinator role.
- Meet deadlines for system entry, responses to inquiries from other departments, and return telephone calls and voicemails.
- Respond to members, providers, and other business areas regarding appeals and grievances status or processes in a timely and professional manner.
- Perform other appeals and grievances support duties as assigned.
Benefits
- Medical, dental, vision, and pharmacy benefits.
- Merit increases.
- Flexible Spending Accounts.
- 403(b) savings matches.
- Paid time off.
- Career advancement opportunities.
- Resources to support employee and family wellbeing.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
