Member Advocate, Appeals and Grievance Coordinator

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 is 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.

Candidates local to our Hingham, MA office are preferred. Rotating weekend coverage is required. This is based off a rotating schedule and only 3 hours on a Saturday is required. Standard work hours are 8a-4p but can flex if needed.

A writing sample will be requested as part of the interview process.

This role is eligible for the eWorker, Moblie, 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 other remote location in the event of a building closure, emergency, or disaster.

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High school degree or equivalent required unless otherwise noted above

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.

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 theconfidence gapandimposter syndromecan 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 ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto 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. For more information on how we work and support that work/life balance visit our "How We Work" Page.