Medicare Appeals Coordinator

About the Role

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world’s leading integrated healthcare systems. The Appeals Coordinator will coordinate, process, investigate, and document all aspects of member complaints across our Medicare line of business. This role is responsible for documenting and guiding the life cycle of all member appeals, maintaining tracking information, working closely with internal stakeholders and external vendors/partners, and ensuring compliance with regulatory and contractual requirements.

Responsibilities

• Handle a large volume of incoming appeals (both formal and informal) from receipt through resolution, ensuring all grievances are resolved within contractual and regulatory timeframes.
• Ensure accurate time management of all work, meeting results 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 other pertinent information.
• Collaborate with key departments on all grievances, including Compliance, Pharmacy, Medical Directors, Sales, and other relevant senior and executive staff.
• Assist with or lead external appeal investigations from regulatory agencies, including CMS, EOHHS, and the Division of Insurance.
• Assist with preparing formal written responses to external regulators.
• Work independently with members on their grievances, providing effective and appropriate information as issues are resolved.
• Aid in the preparation of reports to various collaborators and provide feedback on ways to enhance and improve reporting.
• Stay ahead of changes to health plan policies and procedures, ensuring files prepared for external agencies are accurate, well-written, and meet all parties' needs.
• Participate in team meetings and development work, presenting information accurately and contributing notably to projects.
• Participate in internal and external audits and be receptive to feedback and training.
• Function and excel in a remote environment, handling time-critical appeals and grievance cases.
• Hold self and others accountable to meet commitments and persist in accomplishing objectives despite obstacles.
• Build positive relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Perform other duties as assigned with or without accommodation.

Qualifications

• Bachelor's Degree preferred.
• At least 3-5 years of health plan experience, ideally within customer service, quality, or appeals and grievances areas.
• Experience leading appeals and grievances for Medicare products and plans is highly preferred.
• Bilingual is a plus.

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.

Schedule

• Full-time role with a Monday through Friday schedule, sometime between the hours of 8:00 AM - 6:00 PM EST.
• 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.

Pay

$30.60 - $44.51/Hourly

Working Conditions

• This is a remote role that can be done from most US states.
• Scheduled weekly hours: 40.