About this Medicare Appeals Coordinator role at Mass General Brigham
Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
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.
We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.
The Appeals Coordinator will coordinate, process, investigate, and document all aspects of member complaints across our Medicare line of business.
This role will be responsible for documenting and guiding the life cycle of all member appeals. This includes, but is not limited to, maintaining tracking information, working closely with internal stakeholders and external vendors/partners to quickly resolve cases, communicating orally and/or in writing to all involved parties during the grievances process, and documenting according to established standards for reporting and analysis purposes.
The Appeals Coordinator must have detailed knowledge of all applicable health plan policies and procedures. Regulatory (CMS, DOI, MassHealth) and contractual requirements knowledge and expertise are key elements of this role. Strong customer service and interpersonal skills are mandatory during regular interactions with customers, providers, and external agencies.
Principal Duties and Responsibilities:
• Handle a large volume of incoming appeals (both formal and informal) from receipt through resolution, ensuring that all grievances are resolved within contractual and regulatory timeframes. Ensure accurate time management of all work, ensuring results are met 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 any other pertinent information related to the case.
• Collaborate with key departments on all grievances, including Compliance, Pharmacy, Medical Directors, Sales, and other relevant senior and executive staff.
• Assists with or is lead on external appeal investigation from regulatory agencies, including CMS, EOHHS, and the Division of Insurance
• Assists with preparing formal written responses to external regulators
• Work independently with members on their grievances. Provide effective and appropriate information on an ongoing basis to members as you resolve their issues.
• Aid in the preparation of reports to various collaborators and provide feedback on ways in which reporting can be enhanced and improved.
• Stay ahead of any changes to health plan policies and procedures and work closely with key partners on ensuring that the files being prepared for external agencies are accurate, well-written, and meet the needs of all parties. Participate in team meetings and other development work, ensuring that information is presented accurately and your contribution to any development projects is notable.
• Participate in internal and external audits and be receptive to any feedback and training being offered.
• Ability to function and excel in a remote environment, handling time-critical appeals and grievance cases.
• Hold self and others accountable to meet commitments.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build positive relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Other duties as assigned with or without accommodation.
Qualifications
Education
Bachelor's Degree preferred
Experience
At least 3-5 years of health plan experience, ideally within customer service, quality, or appeals and grievances areas preferred
Experience leading appeals and grievances for Medicare products and plans is highly preferred
Bilingual a plus
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.
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done from most US states
- This is a full-time role with a Monday through Friday schedule, sometime between the hours of 8:00 AM - 6:00 PM EST
- This role includes a 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
- Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This will be confirmed via Microsoft Teams video for all employees
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$30.60 - $44.51/Hourly
Grade
6
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.