Mass General Brigham is seeking a Duals Supervisor, Appeals and Grievances to manage the day-to-day operations and work product of the Duals line of business. This role provides direct supervision to a team handling appeals and grievance processes, ensuring compliance with all regulatory and accreditation guidelines while driving operational efficiency.
What You'll Do
- Facilitate bi-weekly one-on-one and weekly team meetings with appeals and grievance coordinators.
- Identify team training needs and collaborate 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 met.
- Represent the Appeals and Grievances Department in case discussions, ensuring requirements of organizations like NCQA and CMS are represented.
- Ensure timely reporting of appeals and grievances to leadership for dissemination to regulatory agencies and clients.
- Collaborate with internal departments (Customer Service, Provider Network, Claims, etc.) to ensure timely resolution of all cases.
- Meet with internal customers to identify process improvement opportunities.
- Collaborate with leadership on reports and analysis for internal committees including Quality Improvement and Audit and Compliance.
- Chair the Appeal Subcommittee and recommend cases for full review at the larger Appeals Committee.
- Collaborate with leadership on all NCQA matters relating to appeals and grievances.
- Anticipate and 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 designate Mass General Brigham Health Plan as a people-first organization.
What We're Looking For
- Bachelor’s degree or equivalent combination of training and experience.
- At least 5-7 years of health plan operations/appeals and grievance experience.
- At least 2-3 years experience with Medicare and/or Dual Special Needs Programs operations.
- At least 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
- Advanced degree such as a master's or RN.
Team & Environment
You will supervise a team of 4-6 appeals and grievance coordinators and report directly to the Sr. Manager, Appeals and Grievances.
Benefits & Compensation
- Comprehensive benefits.
- Career advancement opportunities.
- Differentials, premiums, and bonuses as applicable.
- Recognition programs.
- Compensation range: $78,000.00 - $113,453.60 annually.
Work Mode
This is a remote position. Candidates should be based near 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.
