Manager Appeals & Grievances
Mass General Brigham Health Plan

Job Info

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While a remote role, this team meets every other month at the office at Assembly Row in Somerville and attendance is highly encouraged.

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. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

The Manager, Appeals and Grievances leads a team responsible for the processing of all Member and Provider Appeals and Grievances for all product lines. Oversight includes appeal and grievance intake, investigation, and resolution. The Manager oversees all aspects of process in accordance state and federal regulations to include the Massachusetts Division of Insurance, Executive Office of Health and Human Services (EOHHS), and the Centers for Medicaid and Medicare Services, as well as the National Committee on Quality Assurance (NCQA) guidelines. The Manager will create, plan, and maintain systems and procedures for operating efficiency, which includes identifying new systems opportunities as well as maximization of existing systems.

The Manager must ensure optimum performance within the Appeals and Grievances Department, while ensuring compliance with all applicable performance standards and regulatory, contractual, and corporate policies and procedures. This is in part achieved through the ongoing training and guidance that the Manager provides to the staff and other departments

The Manager will be expected to utilize industry-standard operational metrics to measure individual and departmental performance and present on those metrics to senior and executive staff at Mass General Brigham Health Plan. In addition to managing the day-to-day activities of the Appeals and Grievance Department, the Manager is an active, visible participant on many cross-functional teams which address strategic and business projects such as cost savings measures, infrastructure efficiencies, regulatory and contractual requirements, and break/fixes.

Principal Duties and Responsibilities:

• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Other duties as assigned with or without accommodation.
• Oversee all processes related to the intake, triaging, coordination, and documentation of all appeals and grievances.
• Maintain quality control processes that ensure all standards for timely acknowledgement, resolution, and documentation standards are consistently met.
• Responsible for maintaining and updating annually at a minimum: appeal and grievance policies and procedures and rights, member correspondence materials, and process manuals consistent with regulatory or contractual changes.
• Ensure timely appeal and grievance reporting to regulatory agencies and contracted clients.
• Collaborate with internal departments as necessary (Customer Service Center, Provider Network, Claims, Utilization Management, Pharmacy) to ensure the timely resolution of all appeals and grievances.
• Meet regularly with internal customers to identify process improvement opportunities.
• Present appeal and grievance reports and analysis to various internal stakeholders including, but not limited to Utilization Management Committee, Operations Committee, Audit and Compliance Committee, and Quality Improvement Committee
• Chair Appeal Committee and Appeal Subcommittee.
• Prepares for and is able to act as a spokesperson on all requests relating to appeal and grievances for state, federal, and quality audits
• Act as liaison to the EOHHS Board of Hearings and the Division of Insurance's Office of Patient Protection in all 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.
• Assesses and coordinates training needs of staff with Training Department.
• Facilitates regular bi-weekly one-on-one meetings and weekly team staff meetings.
• Serves as key contact for internal and external customers regarding appeals and grievances
• Escalates issues to the Department Director as needed.
• Provides leadership, development and mentoring of the staff in order to create a high-performance service culture that is aligned with NHP's strategic goals, objectives, and core values

Qualifications
Qualifications:

• Bachelor's degree required or the equivalent combination of training and experience, plus 5-7 years of related experience.
• Registered nursed preferred.

EEO Statement
Mass General Brigham 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.

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