Appeals & Grievances Coordinator

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Job Summary

Under the Supervisor’s direction, the Member Appeals and Grievances Department Coordinator assists with all operational aspects of the Member Appeals and Member Grievances process for Commercial, TMP and Public Plans products. Responsibilities include, but are not limited to: distribution and classification of cases in compliance with applicable timeframes and regulations, gathering information on behalf of the specialists with external vendors , coordinating the request for medical records, tracking effectuations, facilitating delivery of appeals and related information to key departments and appeals committee members; analyzing and reporting data regarding department processes as requested from management; note trends in Member Appeals and Grievances and notify supervisors of their findings and ensuring professional handling of Medicare Part D Appeals and Fast Track Appeals timely and in compliance with CMS regulations.
The coordinator must possess broad understanding of all products and benefits as well as have an understanding of regulatory requirements and timeframes. The Coordinator routinely interacts with providers and other internal and external constituents.
Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment. The employee must have the ability to learn and apply Tufts Health Plan policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed.

Key Responsibilities/Duties – what you will be doing

KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS* (in order of importance)

Assign new verbal and written appeals and grievances to Appeals and Grievances  specialists

• Enter initial member appeals and grievances data into the system of record and maintain accuracy of appropriate data. 
• Review all incoming appeals for potential expedites, assign and notify management as appropriate.
• Reviews and appropriately classifies grievances and appeals
• Track and ensure the timely distribution of all processes addressed by appeals and grievances specialists.

Process Part D Appeals:

• Gather appeal information and criteria information from department systems
• Outreach to providers for additional information in compliance with CMS guidelines
• Summarize and send requests to Medical Directors for decisions
• Complete decision letters and verbal notification of outcomes according to CMS guidelines
• Process cases according to CMS regulations and time frames

Process Fast Track Appeals  including:

• Monitors Fast Track appeal phone line and RightFax for new cases and notifies A&G management and Case Management representatives via email
• Corresponds with providers and members as required (timely and accurate correspondence and telephone contact as appropriate).
• Acts as a liaison to Case Management for obtaining discharge summary to complete  DENC’s and DNOD’s.
• Completes data entry and documentation requirements in multiple systems.
• Escalates issues to  Manager, Supervisors, and Case Manager Supervisors as needed to complete  DENC’s, and DNOD’s.
• Responsible for compliance with all CMS and Livanta timelines.

Support the specialists in the completion of appeals and grievances including but not limited to

• Requesting and tracking receipt of appropriate medical records
• Gathering information and uploading to the system of record from external vendors
• Identifying and attaching appropriate sections of member EOCs in the appeals file
• Printing and distributing appeals packets as needed
• Track and complete AOR process
• Develop appeals meeting agendas for the various Appeals Committee meetings.
• Assists in departmental reporting

Provide in department projects, as assigned

Qualifications – what you need to perform the job

EDUCATION: (Minimum educations & certifications required)

BA/BS or equivalent in health care, administrative or related field preferred.

EXPERIENCE:  (Years of experience)

1-2 years of experience in a health care and/or administrative setting preferred.

SKILL REQUIREMENTS: (Include interpersonal skills)

Excellent organizational skills required.  Excellent interpersonal/communication skills are essential.  Must have computer skills with experience in EXCEL, and WORD.  Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.  Knowledge of basic medical terminology a plus.

Individual must be able to appropriately identify urgent situations and follow the appropriate protocol.  Position also requires the ability to manage multiple priorities as well as having the initiative, judgment and perception to operate within a fast paced, high stress environment.  Individual must possess strong organizational, logical reasoning, analytical, and problem solving skills as well as the attention to detail necessary to act within this complex environment. Individual must also be able to work independently but be able to identify when they should ask for help.  The individual should be flexible in order to respond to changing needs in the Department.

Must be able to work well independently and as a team member.  Must be able to work closely with other department staff and must have work coverage plan in place in preparation for scheduled and unscheduled absences, due to importance of position to department’s compliance with various processes.

Requires excellent interpersonal skills and an ability to recognize and understand sensitive customer oriented issues.  Position also requires daily contact, by telephone, with members, providers and Tufts HP internal departments.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)

Fast paced office environment handling multiple demands.  Must be able to exercise appropriate judgment as necessary. Work is done in an open office setting with other employees.  Job requires employee to have the ability to distribute large quantities of cases to various departments throughout the company.

In the absence of specific direction, individual must be able to prioritize workload.  Work requires ability to use independent judgment and discretion in decision making which may impact the department.  Individual must utilize various sources of communication such as verbal and written documentation to disseminate information to internal and external customers.

CONFIDENTIAL DATA:  All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential.  Will be exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy and department guidelines/policies and all applicable laws and regulations at all times.

Position requires confidential handling of member information, within and outside of Tufts Health Plan and when speaking to individuals who are acting on behalf of the member.  Person must understand and adhere to department and company’s confidentiality policy.  No inappropriate handling of confidential member information will be tolerated.

Compensation & Total Rewards Overview

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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