It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
The Member Appeals and Grievances (A&G) Program Coordinator oversees administrative functions associated with Member Appeals and Grievances. The A&G Program Coordinator is responsible for collecting and analyzing management and regulatory member appeals and grievance reporting including trend identification for the appeals and grievances management team. Maintains an auditing and monitoring process for Appeals & Grievances. This position is also responsible for identification, intake and distribution of all member appeals and grievances, including Complaint Tracker Module (CTM) grievances for the Senior Care Options program.
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Our Investment in You:- Full-time remote work
- Competitive salaries
- Excellent benefits
Key Functions/Responsibilities:
- Maintain the member appeals and grievances database
- This includes appropriate identification, intake and entry into the database and distribution to the Appeals and Grievances Specialists of all appeals and grievances sent to the Member Appeals and Grievances department
- Responsible for maintaining the integrity of various data sources used for analysis and reporting, requiring precise data entry, implementing automated checks and balances to identify data issues, and developing workflows to minimize manual errors
- Responsible for producing ad hoc analytics related to member appeals and grievances utilizing Access database
- Responsible for abstracting relevant data from various reporting sources, analyzing data and identifying trends and/or areas of concern to be raised to the appeals and grievances management team
- Responsible for regulatory and management appeals and grievances reporting utilizing Access
- Develop and maintain annual calendar of all required reporting and metrics to track deliverables and due dates
- Assist the appeals and grievances management team with audits and maintaining up-to-date auditing and monitoring system
- Create daily, weekly and monthly reports for the appeals and grievances management team as part of the internal auditing and monitoring program
- Reports include analysis and trend identification
- Participate in training including maintenance of up-to-date materials with the appeals and grievances management team and Appeals & Grievances Specialists
- Document and maintain timely minutes for the Member Appeals Committee
- Provide review and editing of appeal and grievance documentation/correspondence as needed
- Other appeals and grievances support duties as assigned
- Meets all required deadlines
Qualifications:
Education:
- Bachelor’s degree in Health Care Administration, related field, or an equivalent combination of education, training, and experience is required
Experience Required:
- Microsoft Office
Experience Preferred:
- Access
- OnBase
- Experience with appeals and grievances
- 2 or more years of experience in a healthcare setting
- Experience with data entry and reporting
- Experience with Medicaid and Medicare preferred
Competencies, Skills, and Attributes:
- Excellent oral, written and interpersonal communication skills required
- Ability to be flexible and work independently, as well as collaborate with other departments across the organization
- Ability to work effectively in a fast paced environment
- Problem solving
- Ability to abstract data, analyze and identify trends
- Strong attention to detail and excellent organizational skills
- Ability to multi task
- Ability to provide high quality customer service
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
- WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.
Required Skills
Required Experience
