While a remote role, this team meets every other month at the office at Assembly Row in Somerville and attendance is highly encouraged. This role would also require on-call coverage on the weekends (currently every third weekend though this need could evolved based on business needs).

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.

Principal Duties and Responsibilities:

* Handle a large volume of incoming grievance and appeals from receipt through resolution, ensuring that all appeals are resolved within contractual timeframes. Ensure accurate time management of all work, ensuring results are met on time and to the best of your ability.
* Document and supervise all appeals and grievances in the appropriate tracking systems, ensuring the quality and accuracy of work is outstanding.
* 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.
* Collaborate with key departments on all appeals and grievances, including Compliance, Pharmacy, Medical Directors, Sales, and other relevant senior and executive staff. Assist in the notification to external agencies of appeal outcomes per MassHealth Board of Hearing and the Division of Insurance's Office of Patient Protection requirements.
* Prepare files for external review when advised 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 effective and appropriate information on an ongoing basis to members as you resolve their issue.
* Work independently with providers on their appeals, which will include resolving payment issues, claims processing issues, and identification of system improvements which in turn will reduce provider appeals.
* Aid in the preparation of reports to various collaborators, whether they are member appeals and grievances, or provider appeals; 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.
* Weekend and holiday on-call coverage will be required to meet the needs of our members and organization.
* Hold self and others accountable to meet commitments.
* Ensure diversity, equity, and inclusion are integrated as a guiding principle.
* 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

• Bachelor's degree required or the equivalent combination of training and experience, plus 3-5 years of related experience in a health plan. Ideally experience within a customer service, quality, or appeals and grievances department; experience in a similar environment such as a large multi-specialty practice or facility would also suffice.
• Experience leading appeals and grievances for Commercial, Medicaid and Medicare products and plans preferred.
• Bilingual a plus.

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. 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 the law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.