Member Advocate, Appeals and Grievance Coordinator
Blue Cross and Blue Shield of Massachusetts, Inc., Hingham, MA, United States
Job Description
The Appeals and Grievance Member Advocate is responsible for the coordination and resolution of Medicare Advantage Part C and Part D Appeals, Grievances, and Part D coverage determinations / redeterminations / reconsiderations and outbound calling. The coordinator ensures compliance with CMS requirements for processing and timeliness. In addition to handling grievances and appeals, the coordinator receives and manages all CTM casework assigned by 1-800-Medicare to the plan.
Candidates local to our Hingham, MA office are preferred. Rotating weekend coverage is required (3 hours on Saturday). Standard work hours are 8am-4pm, with flexibility if needed. A writing sample will be requested as part of the interview process.
Key Responsibilities
Document and track all inbound oral and written Part C and Part D grievances, appeals, coverage determinations, and complaints filed through 1-800-MEDICARE (CTM’s).
Maintain and update a production file for oral and written Part C and Part D grievances, appeals, coverage determinations, and CTM’s.
Meet CMS guidelines for timeliness, data validation, reporting, and resolution of grievances, CTM’s, and appeals as measured by quality initiatives and lead observations of performance.
Monitor all inbound requests, ensuring timeliness requirements are met, proper case categorization and resolution. Escalate as needed to leadership.
Contribute to the collection of quality data; analyze reporting; identify and communicate trends that help drive improvements that support department goals such as STARS, SQM, NCQA and CAHPS.
Review all applicable CMS guidance, SOP’s and reporting requirements; create and update reports.
Support the Help Desk hotline for questions member services will have.
Facilitate and coordinate with internal and external customers in a proactive manner to bring review/appeal to satisfactory resolution.
Participate in mock audits with internal compliance and contractors.
Act as an SME to provide support to other team members and internal customers.
Participate in associate training such as new‑hire, yearly appeals and grievance training and ad hoc training needs.
Identify areas of opportunity to streamline workflows for accuracy, quality, productivity, and make improvements resulting in time savings while affording the highest customer satisfaction.
Other responsibilities as identified by senior leadership.
Education and Experience
3‑5 years of customer service experience.
Knowledge of Medicare and Medicare Advantage is preferred.
Ability to handle complex and confidential matters, including priority and sensitive issues from external and internal members and staff discreetly and confidentially.
Ability to confidently converse with physicians and facility staff.
Ability to present case files and speak to the timeline and actions taken on behalf of the member in both internal mock audits and during CMS audits.
Bachelor’s degree or related experience.
Skills
Ability to organize and prioritize assignments in a fast‑paced policy development environment.
Demonstrate flexibility and the ability to work in a fast‑paced team environment.
Strong decision‑making ability.
Professionalism, team spirit and a customer‑focused orientation.
Discretion and good judgment.
Advanced proficiency in Microsoft Word, Excel, Outlook, Access and PowerPoint.
Excellent communication, telephone, organizational, problem‑solving, writing skills and ability to work independently.
Self‑motivated and able to carry out responsibilities with minimal direction to meet business needs in a high‑volume, fast‑paced, rapidly changing environment.
Compensation and Benefits
Hourly range: $28.20 – $34.47. The posted range reflects the lowest to highest salary the company believes it would pay for this role at the time of posting. Salary may vary based on education, qualifications, experience, skills, performance, shift, travel requirements, and business needs. This job is also eligible for variable pay.
The company offers a comprehensive benefits package including paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits to eligible employees.
Additional Information
This position is essential to operations in the event of building closure due to weather, emergency, or disaster. Employees may be required to bring company‑issued laptops home and work remotely during such events.
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The Appeals and Grievance Member Advocate is responsible for the coordination and resolution of Medicare Advantage Part C and Part D Appeals, Grievances, and Part D coverage determinations / redeterminations / reconsiderations and outbound calling. The coordinator ensures compliance with CMS requirements for processing and timeliness. In addition to handling grievances and appeals, the coordinator receives and manages all CTM casework assigned by 1-800-Medicare to the plan.
Candidates local to our Hingham, MA office are preferred. Rotating weekend coverage is required (3 hours on Saturday). Standard work hours are 8am-4pm, with flexibility if needed. A writing sample will be requested as part of the interview process.
Key Responsibilities
Document and track all inbound oral and written Part C and Part D grievances, appeals, coverage determinations, and complaints filed through 1-800-MEDICARE (CTM’s).
Maintain and update a production file for oral and written Part C and Part D grievances, appeals, coverage determinations, and CTM’s.
Meet CMS guidelines for timeliness, data validation, reporting, and resolution of grievances, CTM’s, and appeals as measured by quality initiatives and lead observations of performance.
Monitor all inbound requests, ensuring timeliness requirements are met, proper case categorization and resolution. Escalate as needed to leadership.
Contribute to the collection of quality data; analyze reporting; identify and communicate trends that help drive improvements that support department goals such as STARS, SQM, NCQA and CAHPS.
Review all applicable CMS guidance, SOP’s and reporting requirements; create and update reports.
Support the Help Desk hotline for questions member services will have.
Facilitate and coordinate with internal and external customers in a proactive manner to bring review/appeal to satisfactory resolution.
Participate in mock audits with internal compliance and contractors.
Act as an SME to provide support to other team members and internal customers.
Participate in associate training such as new‑hire, yearly appeals and grievance training and ad hoc training needs.
Identify areas of opportunity to streamline workflows for accuracy, quality, productivity, and make improvements resulting in time savings while affording the highest customer satisfaction.
Other responsibilities as identified by senior leadership.
Education and Experience
3‑5 years of customer service experience.
Knowledge of Medicare and Medicare Advantage is preferred.
Ability to handle complex and confidential matters, including priority and sensitive issues from external and internal members and staff discreetly and confidentially.
Ability to confidently converse with physicians and facility staff.
Ability to present case files and speak to the timeline and actions taken on behalf of the member in both internal mock audits and during CMS audits.
Bachelor’s degree or related experience.
Skills
Ability to organize and prioritize assignments in a fast‑paced policy development environment.
Demonstrate flexibility and the ability to work in a fast‑paced team environment.
Strong decision‑making ability.
Professionalism, team spirit and a customer‑focused orientation.
Discretion and good judgment.
Advanced proficiency in Microsoft Word, Excel, Outlook, Access and PowerPoint.
Excellent communication, telephone, organizational, problem‑solving, writing skills and ability to work independently.
Self‑motivated and able to carry out responsibilities with minimal direction to meet business needs in a high‑volume, fast‑paced, rapidly changing environment.
Compensation and Benefits
Hourly range: $28.20 – $34.47. The posted range reflects the lowest to highest salary the company believes it would pay for this role at the time of posting. Salary may vary based on education, qualifications, experience, skills, performance, shift, travel requirements, and business needs. This job is also eligible for variable pay.
The company offers a comprehensive benefits package including paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits to eligible employees.
Additional Information
This position is essential to operations in the event of building closure due to weather, emergency, or disaster. Employees may be required to bring company‑issued laptops home and work remotely during such events.
#J-18808-Ljbffr