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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.
Rotating weekend coverage is required.
Writing sample will be requested as part of the interview process.
***This position is eligible in the following personas: E-Worker, Mobile and Resident***
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 updating tracking files 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 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 trainingneeds.
Strong written and verbal communication skills
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.
Excellent communication/telephone, organization and problem-solving skills, writing skills, and the ability to work independently.
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.
Exhibit professionalism; team spirit and a customer-focused orientation required.
Demonstrated ability to exercise tact, discretion and good judgment.
Demonstrate experience in reporting and creation of department metrics using Microsoft Excel.
Education and Experience:
Bachelor's degree or relative experience.
Knowledge of Medical and Pharmacy benefits is preferred.
Demonstrated ability to use Microsoft Outlook, Microsoft Access, and create Power Point presentations.
Knowledge of Medicare requirements and BCBSMA local policies.
Working knowledge with RTMS, NASCO, Mainframe, Blue View and Medicare websites.
Minimum Education Requirements:
High school degree or equivalent required unless otherwise noted above
Location Hingham Time Type Full time
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).
Blue Cross Blue Shield of Massachusetts, has a COVID-19 vaccination requirement. Your offer of employment is dependent upon either being fully vaccinated for COVID-19 or an accommodation based on a disability or sincerely held religious belief, practice, or observance by submitting a request to Human Resources.