Manager, Appeals & Grievances
Manager, Appeals & Grievances
Employer Active
Job Alert
You will be updated with latest job alerts via email
Share
Job Alert
You will be updated with latest job alerts via email
Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
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 worlds 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 welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.
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 Medicaid and Commercial 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 that address strategic and business projects such as cost savings measures infrastructure efficiencies regulatory and contractual requirements and break/fixes.
Qualifications
Principal Duties and Responsibilities:
- Hold self and others accountable to meet commitments.
- 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 the 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 appeals and grievances for state federal and quality audits
- Act as liaison to the EOHHS Board of Hearings and the Division of Insurances 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 the 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 MGB Health Plans strategic goals objectives and core values
Qualifications:
Education
- Bachelors degree required or the equivalent combination of training and experience plus 5-7 years of related experience
Licenses and Credentials
- Registered nurse preferred
Experience
- At least 5-7 years of experience in appeals and grievances required
- At least 2-3 years of experience in a supervisory or management role required
Knowledge Skills and Abilities
- Superior verbal and written communication skills required.
- Sensitivity to confidential materials the ability to maintain a professional demeanor guide subordinates through potentially difficult situations involving providers members and internal customers.
- Able to understand and adhere to complex regulations.
- Medicaid Medicare and Commercial insurance knowledge essential.
- Ability to analyze large volume of data and synthesize for reporting purposes.
- Identify trends and opportunities through appeals and grievance data analysis.
- Demonstrate Mass General Brigham Health Plans core brand principles of always listening challenging conventions and providing value.
- Bring fresh ideas forward by listening to and working with employees and the people we serve.
- Strong demonstrated track record of the ability to execute on time on budget and on scope.
- Strong aptitude for technology-based solutions.
- Ability to inject energy when and where its needed.
- Current in healthcare trends.
- Demonstrated forward visionary thinking; ability to see what is and envision what could be.
- Ability to develop introduce defend and gain support for new ideas and approaches.
- Excellent leadership skills and leadership track record.
- Ability to translate and communicate complex topics in a variety of forums tailoring communications to effectively fit and influence the targeted audience strong executive presence presentation and communication skills. Strong verbal active listening and written communication skills required.
- Ability to view the long-range trends and cycles of the business and industry and see the big picture.
- Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
- Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
- Excellent interpersonal skills including the ability to influence others at all levels of an organization.
- Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
- Unquestionable integrity.
Additional Job Details (if applicable)
Working Conditions
- This role will require an on-site presence at the office at least quarterly for leadership and staff meetings.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
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.
Required Experience:
Manager
Employment Type
Full-Time
