Appeals and Grievance Coordinator
Ready to help us transform healthcare? Bring your true colors to blue.
This position is eligible in the following personas:
E-Worker, Mobile and Resident The Appeals and Grievance Coordinator is responsible for the coordination and resolution of Medicare Advantage Part C and Part D appeals, grievances, and coverage determinations.
The coordinator is also responsible for ensuring compliance with the Centers for Medicare and Medicaid Services (CMS) requirements for processing and timeliness.
In addition to the handling of grievances and appeals, the coordinator receives and manages all CTM casework assigned by 1-800-Medicare to the plan.
Your Day to Day:
Document, maintain and update all inbound oral and written Part C and Part D Grievances, Appeals, Coverage Determinations and Complaints filed through 1-800-MEDICARE (CTM's) Meet CMS guidelines for timeliness, data validation, reporting and resolution of grievances, CTM's and appeal as measured by quality initiatives and leader observations of performance Monitor all inbound requests, ensuring timeliness requirements are met, proper case categorization and resolution.
Escalate as needed to leadership Review all applicable CMS guidance, SOP's and reporting requirements Support First Call Resolution (FCR) by providing high quality service to A&G coordinators and internal business partners by promptly researching and responding to calls received through the A&G Hotline Facilitate and coordinate with internal and external customers in a proactive manner to bring grievance/appeal to satisfactory resolution Report to leadership trends and investigate system discrepancies found during case review for opportunities to streamline workflows for accuracy, quality, productivity, and make improvements resulting in time savings while affording the highest customer service Performs special projects as needed Exhibit a spirit of teamwork and contribute ideas for the team success Provide high level of service to A&G coordinators and to internal customers by promptly responding to emails received in A&G mailbox, IM and work-items and Hotline.
Participate in new hire associate training, Adhoc training and cross training to A&G coordinators Regularly communicate with your leader(s) and team members at meetings and trainings to promote business effectiveness Other responsibilities as identified by Senior Leadership We're Looking For:
Ability to organize and prioritize assignments in a fast-paced environment Customer service experience in the healthcare field is desired Knowledge of Medicare Advantage Medical and Pharmacy benefits is preferred Knowledge of Medicare regulations, guidelines and BCBSMA local policies Excellent communication, telephone, organization, written and problem-solving skills Ability to work independently Working knowledge with ESD, RTMS, NASCO, Blue View, and Medicare websites Excellent PC skills.
Requires knowledge of Microsoft Word, outlook, and Excel Solid decision-making ability and attention to detail Ability to confidently converse with physicians and clinical staff Ability to handle complex, sensitive, and confidential matters from external and internal members and staff discreetly and confidentially Ability to assist researching case files in both internal audits and during CMS Audits What You Bring:
Bachelor's degree or relative experience Minimum of 2-3 year's operations experience Strong knowledge of Microsoft Office Suite:
Word, Outlook, PowerPoint and Excel #LI-REMOTEMinimum Education Requirements:
High school degree or equivalent required unless otherwise noted aboveLocationHinghamTime TypeFull timeHourly Range:
$25.
89 - $31.
65The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting.
We may ultimately pay more or less than the posted range, and the range may be modified in the future.
An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.
This job is also eligible for variable pay.
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note:
No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable.
The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
WHY Blue Cross Blue Shield of MA?We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply.
We'd love to hear from you.
You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA.
The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant.
We encourage you to bring us your true colors, , your perspectives, and your experiences.
It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.
As an employer, we are committed to investing in your development and providing the necessary resources to enable your success.
Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page.
If this sounds like something you'd like to be a part of, we'd love to hear from you.
You can also join our Talent Community to stay in the know on all things Blue.
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing.
We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).
Recommended Skills Attention To Detail Auditing Clinical Works Communication Content Management Customer Service Estimated Salary: $20 to $28 per hour based on qualifications.
This position is eligible in the following personas:
E-Worker, Mobile and Resident The Appeals and Grievance Coordinator is responsible for the coordination and resolution of Medicare Advantage Part C and Part D appeals, grievances, and coverage determinations.
The coordinator is also responsible for ensuring compliance with the Centers for Medicare and Medicaid Services (CMS) requirements for processing and timeliness.
In addition to the handling of grievances and appeals, the coordinator receives and manages all CTM casework assigned by 1-800-Medicare to the plan.
Your Day to Day:
Document, maintain and update all inbound oral and written Part C and Part D Grievances, Appeals, Coverage Determinations and Complaints filed through 1-800-MEDICARE (CTM's) Meet CMS guidelines for timeliness, data validation, reporting and resolution of grievances, CTM's and appeal as measured by quality initiatives and leader observations of performance Monitor all inbound requests, ensuring timeliness requirements are met, proper case categorization and resolution.
Escalate as needed to leadership Review all applicable CMS guidance, SOP's and reporting requirements Support First Call Resolution (FCR) by providing high quality service to A&G coordinators and internal business partners by promptly researching and responding to calls received through the A&G Hotline Facilitate and coordinate with internal and external customers in a proactive manner to bring grievance/appeal to satisfactory resolution Report to leadership trends and investigate system discrepancies found during case review for opportunities to streamline workflows for accuracy, quality, productivity, and make improvements resulting in time savings while affording the highest customer service Performs special projects as needed Exhibit a spirit of teamwork and contribute ideas for the team success Provide high level of service to A&G coordinators and to internal customers by promptly responding to emails received in A&G mailbox, IM and work-items and Hotline.
Participate in new hire associate training, Adhoc training and cross training to A&G coordinators Regularly communicate with your leader(s) and team members at meetings and trainings to promote business effectiveness Other responsibilities as identified by Senior Leadership We're Looking For:
Ability to organize and prioritize assignments in a fast-paced environment Customer service experience in the healthcare field is desired Knowledge of Medicare Advantage Medical and Pharmacy benefits is preferred Knowledge of Medicare regulations, guidelines and BCBSMA local policies Excellent communication, telephone, organization, written and problem-solving skills Ability to work independently Working knowledge with ESD, RTMS, NASCO, Blue View, and Medicare websites Excellent PC skills.
Requires knowledge of Microsoft Word, outlook, and Excel Solid decision-making ability and attention to detail Ability to confidently converse with physicians and clinical staff Ability to handle complex, sensitive, and confidential matters from external and internal members and staff discreetly and confidentially Ability to assist researching case files in both internal audits and during CMS Audits What You Bring:
Bachelor's degree or relative experience Minimum of 2-3 year's operations experience Strong knowledge of Microsoft Office Suite:
Word, Outlook, PowerPoint and Excel #LI-REMOTEMinimum Education Requirements:
High school degree or equivalent required unless otherwise noted aboveLocationHinghamTime TypeFull timeHourly Range:
$25.
89 - $31.
65The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting.
We may ultimately pay more or less than the posted range, and the range may be modified in the future.
An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.
This job is also eligible for variable pay.
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note:
No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable.
The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
WHY Blue Cross Blue Shield of MA?We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply.
We'd love to hear from you.
You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA.
The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant.
We encourage you to bring us your true colors, , your perspectives, and your experiences.
It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.
As an employer, we are committed to investing in your development and providing the necessary resources to enable your success.
Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page.
If this sounds like something you'd like to be a part of, we'd love to hear from you.
You can also join our Talent Community to stay in the know on all things Blue.
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing.
We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).
Recommended Skills Attention To Detail Auditing Clinical Works Communication Content Management Customer Service Estimated Salary: $20 to $28 per hour based on qualifications.
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