Member Appeals and Grievances Coordinator

WellSense Health Plan; Boston (MA); On-site; USD 28,000 - 39,000; Full time

Benefits offered by this job

Medical, dental, vision benefits

403(b) savings match

Paid time off

Flexible Spending Accounts

Career advancement opportunities

Wellbeing resources

Job summary

WellSense Health Plan is seeking a detailed-oriented Member Appeals and Grievances Coordinator in the Boston area. The role focuses on intake and routing of member appeals and grievances, accurate data entry, and maintaining secure records in the A&G system.

You will work with multiple teams to ensure timely responses and compliance. Responsibilities include trend reporting, audits, and training support for new staff while meeting deadlines and providing high-quality member service in a

Qualifications

• Bachelor’s degree in Health Care Administration, related field, or equivalent combination of education, training and experience.
• Experience with Microsoft Office and healthcare management systems.
• Ability to identify problems, collect data, and draw valid conclusions.

Responsibilities

• Identify and intake appeals and grievances in a compliant, timely manner.
• Enter data accurately into the A&G system of record and distribute to specialists.
• Maintain organized record keeping and respond to inquiries from other departments.
• Generate daily/weekly/monthly reports for management audits and monitoring.
• Collaborate with A&G leadership and staff; participate in training as needed.

Skills

Microsoft Office Applications

Proprietary healthcare management sys

Problem solving

Education

Bachelor’s degree in Health Care Administration

Tools

JIVA

Express Scripts

HPMS

Access

Job description

Member Appeals and Grievances Coordinator

WellSense Health Plan is a nonprofit health insurance company serving more than 680,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded more than 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Member Appeals and Grievances (A&G) Coordinator performs administrative functions associated with incoming Member Appeals and Grievances. The A&G Coordinator is responsible for identification, intake, and distribution of member appeals and grievances. The A&G Coordinator maintains organized, secure, and efficient record keeping processes. The A&G Coordinator is responsible for responding to other business areas and members / providers regarding status of appeals and grievances or A&G processes in a timely and professional manner. The A&G Coordinator establishes and maintains collaborative and meaningful interdepartmental relationships.

Our Investment in You:

Key Functions/Responsibilities:

• Appropriate and compliant identification of appeals and grievances during intake. Accurate and detailed entry into the A&G system of record. Timely distribution of all appeals and grievances to the Appeals and Grievances Specialists in accordance with department rules and deadlines.
• Responsible for data accuracy during entry into the A&G system of record to support the integrity of trend analysis and reporting and development/management of appropriate workflows to minimize manual errors and ensure compliance and consistency.
• Responsible for identifying trends and/or areas of concern to be raised to the A&G Management team.
• Assist the A&G Management team with audits and reporting needs as necessary and applicable.
• Participation / creation of daily, weekly and / or monthly reports for the A&G Management team as part of the internal auditing and monitoring program. Reports include analysis and trend identification.
• Participate in or lead training with the A&G Management team, A&G Specialists and / or new Coordinator staff. Includes maintenance of up-to-date materials related to the Coordinator role.
• Meets all required deadlines for entry into the A&G system of record, responses to inquiries from other departments, return telephone calls / voicemails, etc.
• Other appeals and grievances support duties as assigned.

Supervision Exercised:

• None

Supervision Received:

• Direct supervision is received weekly.

Qualifications:

Education:

• Bachelor’s degree in Health Care Administration, related field, or an equivalent combination of education, training, and experience is required.

Experience Required:

• Microsoft Office Applications
• Demonstrated ability to use proprietary healthcare management system(s)
• Proven ability to identify problems and procedural irregularities, collect data, establish facts, and draw valid conclusions

Experience Preferred:

• JIVA
• Express Scripts, Inc
• HPMS
• Access
• 2 or more years of experience in a healthcare setting, specifically related to Appeals and Grievances
• Experience with data entry, trend analysis, and reporting
• Experience with health insurance (Commercial, Medicaid and Medicare)
• Experience with rules and regulations governing health insurance (Commercial, Medicaid and Medicare)
• Experience communicating with a provider network
• Certified Professional Coder (CPC) certification

Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes:

• Excellent attention to detail and excellent organizational skills
• Excellent oral, written and interpersonal communication skills required
• Ability to be flexible and work independently, as well as collaborate with other departments across the organization
• Ability to work effectively in a fast paced environment
• Problem solving
• Ability to abstract data, analyze and identify trends
• Ability to multi task
• Ability to provide high quality customer service

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Flexibility to work some evening / weekend hours if necessary
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.

Compensation Range

$20.19- $28.13

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees