M
Medicare Appeals Coordinator
Mass General Brigham
10 hours ago
Full-time
On-site
Somerville, Massachusetts, United States
Registered Nurse
Site: Mass General Brigham Health Plan Holding Company, Inc.
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
Remote
Work Location
399 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
Pay Range
$30.60 - $44.51/Hourly
Grade
6
At Mass General Brigham, we believe in recognizing and rewarding the unique
value each team member brings to our organization. Our approach to determining
base pay is comprehensive, and any offer extended will take into account your
skills, relevant experience if applicable, education, certifications and other
essential factors. The base pay information provided offers an estimate based on
the minimum job qualifications; however, it does not encompass all elements
contributing to your total compensation package. In addition to competitive base
pay, we offer comprehensive benefits, career advancement opportunities,
differentials, premiums and bonuses as applicable and recognition programs
designed to celebrate your contributions and support your professional growth.
We invite you to apply, and our Talent Acquisition team will provide an overview
of your potential compensation and benefits package.
EEO Statement:
8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal
Opportunity Employer. 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. To
ensure reasonable accommodation for individuals protected by Section 503 of the
Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and
Title I of the Americans with Disabilities Act of 1990, applicants who require
accommodation in the job application process may contact Human Resources at
(857)-282-7642.
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.
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
Remote
Work Location
399 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
Pay Range
$30.60 - $44.51/Hourly
Grade
6
At Mass General Brigham, we believe in recognizing and rewarding the unique
value each team member brings to our organization. Our approach to determining
base pay is comprehensive, and any offer extended will take into account your
skills, relevant experience if applicable, education, certifications and other
essential factors. The base pay information provided offers an estimate based on
the minimum job qualifications; however, it does not encompass all elements
contributing to your total compensation package. In addition to competitive base
pay, we offer comprehensive benefits, career advancement opportunities,
differentials, premiums and bonuses as applicable and recognition programs
designed to celebrate your contributions and support your professional growth.
We invite you to apply, and our Talent Acquisition team will provide an overview
of your potential compensation and benefits package.
EEO Statement:
8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal
Opportunity Employer. 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. To
ensure reasonable accommodation for individuals protected by Section 503 of the
Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and
Title I of the Americans with Disabilities Act of 1990, applicants who require
accommodation in the job application process may contact Human Resources at
(857)-282-7642.
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.