Note: The job is a remote job and is open to candidates in USA. Mass General Brigham Health Plan is a healthcare organization providing member-focused health coverage and services. The Appeals Coordinator coordinates, processes, investigates, and documents Medicare member appeals and grievances, ensuring timely resolution, regulatory compliance, accurate records, and effective communication with members and stakeholders.
Responsibilities
- Handle a large volume of incoming appeals (both formal and informal) from receipt through resolution, ensuring that all grievances are resolved within contractual and regulatory timeframes. Ensure accurate time management of all work, ensuring results are met on time with high-quality standards
- Document and supervise all grievances in the appropriate tracking systems, ensuring the highest quality and accuracy of work
- Ensure 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 grievances, including Compliance, Pharmacy, Medical Directors, Sales, and other relevant senior and executive staff
- Assists with or is lead on external appeal investigation from regulatory agencies, including CMS, EOHHS, and the Division of Insurance
- Assists with preparing formal written responses to external regulators
- Work independently with members on their grievances. Provide effective and appropriate information on an ongoing basis to members as you resolve their issues
- Aid in the preparation of reports to various collaborators and 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
- Hold self and others accountable to meet commitments
- 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
Skills
- • 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
- • This is a remote role that can be done from most US states
- • This is a full-time role with a Monday through Friday schedule, sometime between the hours of 8:00 AM - 6:00 PM EST
- • This role includes a rotating holiday coverage requirement; holidays are shared among team members on a scheduled rotation
- • Occasional work on Saturday is required to review inboxes for any urgent requests and triage
- • Bachelor's Degree preferred
- • At least 3-5 years of health plan experience, ideally within customer service, quality, or appeals and grievances areas preferred
- • Experience leading appeals and grievances for Medicare products and plans is highly preferred
- • Bilingual a plus
Benefits
- Flexible work options
- Career growth opportunities
- Comprehensive benefits
- Career advancement opportunities
- Differentials as applicable
- Premiums as applicable
- Bonuses as applicable
- Recognition programs designed to celebrate your contributions and support your professional growth
- Remote work arrangement
Company Overview