Member Advocate, Appeals and Grievance Coordinator
Blue Cross Blue Shield of Massachusetts, Hingham, MA, United States
Overview
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, re‑determinations, reconsiderations and outbound calling. The coordinator ensures compliance with CMS requirements for processing and timeliness. In addition to handling grievances and appeals, the coordinator manages all CTM casework assigned by 1‑800‑Medicare to the plan. Candidates local to the Hingham, MA office are preferred. Rotating weekend coverage is required: only three hours on a Saturday per week. Standard work hours are 8 a.m. – 4 p.m., but can flex if needed. A writing sample will be requested as part of the interview process. This role is eligible for the eWorker, Mobile, and Resident personas.
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 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.
Contribute to the collection of quality data; analyze reporting; identify and communicate trends that help drive improvements that will 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 a 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 opportunities 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 Customer Service experience.
Knowledge of Medicare and Medicare Advantage is preferred.
Ability to handle complex and confidential matters. This should include ability to identify and handle priority and/or 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 relative 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.
Solid decision‑making ability.
Exhibit professionalism; team spirit and a customer‑focused orientation required.
Demonstrated ability to exercise tact, discretion and good judgment.
Excellent PC skills. Requires an advanced knowledge of Microsoft Word and Excel. Demonstrated ability to use Microsoft Outlook, Microsoft Access, and create Power Point presentations.
Excellent communication, telephone, organization, and problem‑solving skills, writing skills, and the ability to work independently.
Self‑motivated with the ability to carry out responsibilities with minimal direction to meet business needs in a high volume, fast‑paced and rapidly changing environment.
This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company‑issued laptop home and work from home or another remote location in the event of a building closure, emergency, or disaster.
Location
Hingham
Time Type
Full time
Compensation and Benefits
Hourly Range: $28.20 – $34.47. The 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. Benefits include paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits to eligible employees.
Minimum Education Requirements
High school degree or equivalent required unless otherwise noted above.
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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, re‑determinations, reconsiderations and outbound calling. The coordinator ensures compliance with CMS requirements for processing and timeliness. In addition to handling grievances and appeals, the coordinator manages all CTM casework assigned by 1‑800‑Medicare to the plan. Candidates local to the Hingham, MA office are preferred. Rotating weekend coverage is required: only three hours on a Saturday per week. Standard work hours are 8 a.m. – 4 p.m., but can flex if needed. A writing sample will be requested as part of the interview process. This role is eligible for the eWorker, Mobile, and Resident personas.
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 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.
Contribute to the collection of quality data; analyze reporting; identify and communicate trends that help drive improvements that will 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 a 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 opportunities 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 Customer Service experience.
Knowledge of Medicare and Medicare Advantage is preferred.
Ability to handle complex and confidential matters. This should include ability to identify and handle priority and/or 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 relative 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.
Solid decision‑making ability.
Exhibit professionalism; team spirit and a customer‑focused orientation required.
Demonstrated ability to exercise tact, discretion and good judgment.
Excellent PC skills. Requires an advanced knowledge of Microsoft Word and Excel. Demonstrated ability to use Microsoft Outlook, Microsoft Access, and create Power Point presentations.
Excellent communication, telephone, organization, and problem‑solving skills, writing skills, and the ability to work independently.
Self‑motivated with the ability to carry out responsibilities with minimal direction to meet business needs in a high volume, fast‑paced and rapidly changing environment.
This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company‑issued laptop home and work from home or another remote location in the event of a building closure, emergency, or disaster.
Location
Hingham
Time Type
Full time
Compensation and Benefits
Hourly Range: $28.20 – $34.47. The 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. Benefits include paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits to eligible employees.
Minimum Education Requirements
High school degree or equivalent required unless otherwise noted above.
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