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 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 or equivalent years of experience

Experience

At least 3-5 years of health plan experience, ideally within customer service, quality, or appeals and grievances areas.Experience in Medicare appeals is highly preferred

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 that can be done from most US states. There is a quarterly team meeting at the office in Somerville, MA, where attendance is highly encouraged

 

Remote Type

Remote

 

Work Location

399 Revolution Drive

 

Scheduled Weekly Hours

40

 

Employee Type

Regular

 

Work Shift

Day (United States of America)

 

Pay Range

$30.00 - $43.63/Hourly

 

Grade

6

 

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

 

EEO Statement:

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

 

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.