Supervisor, Appeals and Grievances

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jan 01, 2025
This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA. The Supervisor, Appeals and Grievances provides day-to-day supervision of a team of 4-6 appeals and grievance coordinators and is ultimately responsible for the work product of this team. The Supervisor oversees all aspects of the Appeal and Grievance processes in accordance with the Massachusetts Division of Insurance and Executive Office of Health and Human Services (EOHHS) requirements, the Centers for Medicare and Medicaid Services (CMS), as well as the National Committee on Quality Assurance (NCQA) guidelines. The Supervisor will lead the efforts to coordinate daily operations which includes identifying/communicating any areas of risk and achieving maximum efficiency across all appeal and grievance processes. The Supervisor collaborates with the Director of Appeals and Grievances, as well as other senior and executive staff, to 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. The Supervisor will be expected to work closely with the Director, Appeals and Grievances to identify industry-standard operational metric measure and compare benchmarks to individual and departmental performance. The Supervisor will be responsible for presenting the metric to the Director, Appeals and Grievances and proposing any solutions to identified areas of opportunity. In addition to supervising the day-to-day activities of the Appeals and Grievance Department, the Supervisor 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. Principal Duties and Responsibilities: * Facilitates regular bi-weekly one-on-one meetings and weekly team staff meetings with the Appeals and Grievances department. * Identifies the training needs of the coordinators and works with key stakeholders, including the Learning and Development Dept, Customer Service, Product, etc., to develop training guides and curriculum * Provide real- time oversight and education to the staff to ensure they are meeting their goals related to the intake, triaging, coordination, and documentation of all appeals and grievances * Collaborates with the auditing team to identify and maintain quality control processes that ensure all standards for timely acknowledgment, resolution, and documentation standards are met consistently. * Represents the Appeals and Grievances Dept at the Customer Service Leadership Teams where cases are discussed and follow-up steps are identified; ensure the requirements of various organizations (NCQA, CMS, etc.) are represented. * Ensure timely appeal and grievance reporting to the Director, Appeals and Grievances for dissemination 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. * Collaborates with the Director, Appeals and Grievances on appeal and grievance reports and analysis to various internal stakeholders including, but not limited to, the Quality Improvement Committee, the Utilization Management Committee, and the Audit and Compliance Commit * Chair the Appeal Subcommittee and recommend cases for full review at the larger Appeals Committee. * Collaborates with the Director of Appeals and Grievances on all NCQA 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. * Escalates issues to the Department Director as needed. * Hold self and others accountable to meet commitments. * Ensure diversity, equity, and inclusion are integrated as a guiding principle. * 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. Qualifications: * Bachelor's degree required or the equivalent combination of training and experience. * At least 5-7 years of health plan operations/appeals and grievance experience required. * At least 3 years of experience managing and training staff, ideally within an appeals and grievances department, whether in a formal or informal capacity required. * Advanced degree such as a master's or RN preferred. * Experience representing and solving the needs of staff including executive staff. * Experience setting up appeals and grievances workflows across new products and plans. About Us: 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 consciously inclusive environment where diversity is celebrated. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more. 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/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.