The incumbent will coordinate, process, and document all aspects of member appeals and grievances across all of our Government Program product offerings (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.
Does this position require Patient Care?
No
Essential Functions
- Handle a large volume of incoming grievance 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.
Education
- Bachelor's Degree Related Field of Study preferred
Can this role accept experience in lieu of a degree?
Yes
Experience
- Health plan experience, ideally within customer service, quality or appeals and grievances area. 3-5 years required
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.
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%)
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.
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Mass General Brigham Health Plan
Feb 19, 2025