CareHarmony is hiring a Duals Supervisor, Appeals and Grievances to provide day-to-day supervision for a team of 4-6 appeals and grievance coordinators. In this role, you will be ultimately responsible for the team’s work product and the Duals line of business, overseeing all aspects of the appeal and grievance processes in accordance with regulatory requirements. You will lead efforts to coordinate daily operations, identify risk, and achieve maximum efficiency.
What You'll Do
- Facilitate regular bi-weekly one-on-one meetings and weekly team staff meetings.
- Identify training needs and work with stakeholders to develop training guides and curriculum.
- Provide real-time oversight and education to staff to ensure goals for intake, triage, coordination, and documentation are met.
- Collaborate with the auditing team to maintain quality control processes, ensuring standards for timely acknowledgment, resolution, and documentation are consistently met.
- Represent the department in case discussions, ensuring requirements of organizations like NCQA and CMS are met.
- Ensure timely appeal and grievance reporting to leadership for dissemination to regulatory agencies and clients.
- Collaborate with internal departments (Customer Service, Provider Network, Claims, etc.) to ensure timely case resolution.
- Meet with internal customers to identify process improvement opportunities.
- Collaborate with leadership on reports and analysis for committees like Quality Improvement and Audit and Compliance.
- Chair the Appeal Subcommittee and recommend cases for full review.
- Collaborate with leadership on all NCQA matters relating to appeals and grievances.
- Anticipate and meet or exceed customer expectations, establishing effective relationships.
- Escalate issues to senior leadership as needed.
- Hold self and others accountable to meet commitments.
- Persist in accomplishing objectives despite obstacles.
- Build strong relationships and infrastructures that support a people-first organization.
- Perform other duties as assigned.
What We're Looking For
- Bachelor’s degree or equivalent combination of training and experience.
- 5-7 years of health plan operations and appeals/grievance experience.
- 2-3 years of experience with Medicare and/or Dual Special Needs Programs operations.
- 3+ years of experience managing and training staff, ideally within an appeals and grievances department.
- Experience representing and solving the needs of staff, including executive staff.
- Experience setting up appeals and grievances workflows across new products and plans.
Nice to Have
- An advanced degree such as a master's or RN.
Team & Environment
You will lead a team of 4-6 appeals and grievance coordinators and report to the Sr. Manager, Appeals and Grievances. You will be part of a high-performing, people-first organization.
Benefits & Compensation
- Salary range: $78,000.00 - $113,453.60/Annual
Work Mode
This is a remote position. The company location is Somerville, MA.
Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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.
