Manager, Appeals & Grievances

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, including but not limited to the Utilization Management Committee, Operations Committee, Audit and Compliance Committee, and Quality Improvement Committee
• Chair Appeal Committee and Appeal Subcommittee.
• Prepares for and is able to act as a spokesperson on all requests relating to appeals and grievances for state, federal, and quality audits
• Act 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.
• 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.
• Assesses and coordinates training needs of staff with the Training Department.
• Facilitates regular bi-weekly one-on-one meetings and weekly team staff meetings.
• Serves as key contact for internal and external customers regarding appeals and grievances
• Escalates issues to the Department Director as needed.
• Provides leadership, development, and mentoring of the staff in order to create a high-performance service culture that is aligned with MGB Health Plan's strategic goals, objectives, and core values

Qualifications:

Education

• Bachelor's degree required or the equivalent combination of training and experience, plus 5-7 years of related experience

Licenses and Credentials

• Registered nurse preferred

Experience

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

Knowledge, Skills and Abilities

• Superior verbal and written communication skills required.
• Sensitivity to confidential materials, the ability to maintain a professional demeanor, guide subordinates through potentially difficult situations involving providers, members, and internal customers.
• Able to understand and adhere to complex regulations.
• Medicaid, Medicare, and Commercial insurance knowledge essential.
• Ability to analyze large volume of data and synthesize for reporting purposes.
• Identify trends and opportunities through appeals and grievance data analysis.
• Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and working with employees and the people we serve.
• Strong, demonstrated track record of the ability to execute on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it's needed.
• Current in healthcare trends.
• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."
• Ability to develop, introduce, defend, and gain support for new ideas and approaches.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required.
• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity.

Working Conditions

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