Manager, Appeals and Grievances

Overview

The role leads a team responsible for the processing of all Member Appeals and Grievances for Medicaid and Commercial product lines. Oversight includes appeal and grievance intake, investigation, and resolution. The position 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 role 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 position 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 leader provides to the staff and other departments.

The role is 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 role 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.

• 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 acknowledgment, 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.
• Leads the appeals and grievances team, including hiring, training, and evaluating staff performance.
• Develops and implements policies and procedures to ensure compliance with payer guidelines and regulatory requirements.
• 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.
• 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.
• Prepares for and is able to act as a spokesperson on all requests relating to appeals and grievances for state, federal, and quality audits. Acts as liaison to the EOHHS Board of Hearings and the Division of Insurance's Office of Patient Protection in all matters relating to appeals and grievances.

• Bachelor's Degree or the equivalent combination of training and experience required

• Massachusetts Registered Nurse (RN) license required

• At least 5-7 years of experience in appeals or grievances required
• At least 2-3 years in a supervisory or management role required

• Comprehensive knowledge of healthcare regulations, payer requirements, and billing practices.
• Medicaid, Medicare, and Commercial insurance knowledge is essential.
• Ability to analyze large volume of data and synthesize for reporting purposes.
• Strong leadership and team management abilities.
• In-depth knowledge of payer appeals processes and claim denial management.
• Excellent analytical and problem-solving skills for identifying trends and process improvements.
• Proficiency in revenue cycle management tools and reporting systems.
• Effective communication and interpersonal skills for collaboration and conflict resolution.
• Ability to manage multiple…