Appeals & Grievances Coordinator at Partner's Healthcare in Somerville, Massachusetts

Job Description:

Site: Mass General Brigham Health Plan Holding Company, Inc.


At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission-from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.


At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare - people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds - to apply.



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.


Essential Functions
-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.



Qualifications



Education

• Bachelor's Degree Related Field of Study required

Can this role accept experience in lieu of a degree?
No



Experience

• At least 3-5 years of health plan experience, ideally within customer service, quality or appeals and grievances area

Knowledge, Skills, and Abilities

• 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.

Additional Job Details (if applicable)



Working Conditions

• This is a remote role with an onsite presence at the office in Somerville, MA 1x/every other month.

Physical Requirements

• Standing Occasionally (3-33%)


• Walking Occasionally (3-33%)


• Sitting Constantly (67-100%)


• Lifting Occasionally (3-33%) 20lbs - 35lbs


• Carrying Occasionally (3-33%) 20lbs - 35lbs


• Pushing Rarely (Less than 2%)


• Pulling Rarely (Less than 2%)


• Climbing Rarely (Less than 2%)


• Balancing Occasionally (3-33%)


• Stooping Occasionally (3-33%)


• Kneeling Rarely (Less than 2%)


• Crouching Rarely (Less than 2%)


• Crawling Rarely (Less than 2%)


• Reaching Occasionally (3-33%)


• Gross Manipulation (Handling) Constantly (67-100%)


• Fine Manipulation (Fingering) Frequently (34-66%)


• Feeling Constantly (67-100%)


• Foot Use Rarely (Less than 2%)


• Vision - Far Constantly (67-100%)


• Vision - Near Constantly (67-100%)


• Talking Constantly (67-100%)


• Hearing Constantly (67-100%)

Remote Type


Remote



Work Location


399 Revolution Drive



Scheduled Weekly Hours


40



Employee Type


Regular



Work Shift


Day (United States of America)



EEO Statement:


Mass General Brigham Health Plan Holding Company, Inc. 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 law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.




Mass General Brigham Competency Framework



At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Apply Now