Appeals Coordinator

Mass General Brigham Health Plan; Somerville (MA); Remote; USD 60,000 - 80,000; Full time

Job summary

A health plan provider is seeking an Appeals Coordinator to manage and document member and provider appeals. Responsibilities include tracking appeals, communicating with stakeholders, and ensuring timely resolution. Candidates should hold a Bachelor's degree and have 3-5 years of experience in health plans, particularly in customer service or appeals. This is a remote role, allowing flexibility across most US states.

Qualifications

• 3-5 years of health plan experience in customer service, quality, or appeals and grievances.
• Strong aptitude for technology-based solutions.
• Excellent communication skills.

Responsibilities

• Coordinate and document member appeals and grievances.
• Handle incoming grievances and appeals from receipt through resolution.
• Prepare reports for various stakeholders.
• Work independently to assist members with appeals.

Skills

Strong aptitude for technology-based solutions

Strong customer service skills

Excellent communication skills

Ability to adapt to changing priorities

Excellent organizational abilities

Education

Bachelor's Degree Related Field of Study

Job description

Overview

The incumbent will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all 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: 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.

Responsibilities

• 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, acknowledgement 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 required

Experience

• At least 3-5 years of health plan experience, ideally within customer service, quality or appeals and grievances area 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.

Working Conditions

• This is a remote role that can be done from most US states

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.