Manager, Appeals & Grievances

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.

 

This role will require an on-site presence at the office at least quarterly for leadership and staff meetings.

 

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. 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, inclu