Appeals & Grievances Coordinator

Role Summary

The incumbent will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across our product offerings (Commercial, Medicaid, Medicare). Responsible for documenting and owning the life cycle صرف member and provider appeals. This includes maintaining tracking information, working closely with internal and external stakeholders to resolve cases quickly, communicating orally and in writing, and compiling reports for analysis.

• Handle a large volume of incoming grievances and appeals from receipt through resolution, ensuring that all appeals are resolved within contractual time frames.
• Document and track all appeals and grievances in the appropriate tracking systems, ensuring quality and accuracy.
• Ensure appeal and grievance files are complete and contain all relevant documentation, including research materials, acknowledgment and resolution letters, and otheroubles pertinent information.
• Assist in the preparation of reports to various stakeholders and provide feedback on ways in which reporting can be enhanced.
• Prepare files for external review when an external hearing is requested.
• Work independently with members on their appeals (administrative, clinical, pharmacy) and grievances收益 providing helpful information.
• Resolve payment issues, claims processing issues, and identify system improvements to reduce provider appeals.

Bachelor's degree in a related field of study preferred.

Can this role accept experience in lieu of a degree? Yes.

At least 3‑5 years of health plan experience, ideally within customer service, quality or appeals and grievances area.

• 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.

• Remote role; the team meets quarterly at Assembly Row in Somerville and attendance highly encouraged.
• Typical schedule:
  
  Tuesday through Saturday 8:30 AM–5:00 PM EDT.
• The role includes an on-call component on weekends, roughly every six weeks.

Mass General Brigham Health Plan Holding Company, Inc. 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 other statuses protected under law. We will ensure that all individuals with a disability receive reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.