Duals Supervisor, Appeals and Grievances

About the role

The Duals Supervisor, Appeals and Grievances, is responsible for overseeing a team of 4-6 appeals and grievance coordinators. This position ensures that all processes comply with regulatory and contractual requirements, and supports the overall performance of the Appeals and Grievances Department.

Responsibilities

• Facilitates regular bi-weekly one-on-one meetings and weekly team staff meetings with the Appeals and Grievances department.
• Identifies the training needs of the coordinators and works with key stakeholders to develop training guides and curriculum.
• Provides real-time oversight and education to the staff to ensure they are meeting their goals related to the intake, triaging, coordination, and documentation of all appeals and grievances.
• Collaborates with the auditing team to identify and maintain quality control processes that ensure all standards for timely acknowledgment, resolution, and documentation standards are met consistently.
• Represents the Appeals and Grievances Dept where cases are discussed and follow-up steps are identified; ensure the requirements of various organizations (NCQA, CMS, etc.) are represented.
• Ensures timely appeal and grievance reporting to leadership for dissemination to regulatory agencies and contracted clients.
• Collaborates with internal departments as necessary (Customer Service Center, Provider Network, Claims, Utilization Management, Pharmacy) to ensure the timely resolution of all appeals and grievances.
• Meets regularly with internal customers to identify process improvement opportunities.
• Collaborates with leadership on appeal and grievance reports and analysis to various internal stakeholders including, but not limited to, the Quality Improvement Committee, the Utilization Management Committee, and the Audit and Compliance Committee.
• Collaborates with the leadership on all NCQA matters relating to appeals and grievances.
• Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
• Escalates issues to the senior leadership as needed.
• Holds self and others accountable to meet commitments.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Builds strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.

Qualifications

• Associate's degree required.
• At least 3-5 years of billing, claims, or appeals management experience required.
• At least 1-2 years of experience in a supervisory or leadership role, training staff, ideally within an appeals and grievances department, whether in a formal or informal capacity, preferred.
• At least 5-7 years of health plan operations/appeals and grievance experience is highly preferred.
• At least 2-3 years' experience with Medicare and/or Dual Special Needs Programs operations is highly preferred.