Fallon Health Manager, Member Appeals & Grievances in Worcester, Massachusetts

Overview

About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Summary:

The Manager of Member Appeals & Grievances is responsible for the oversight of the daily operational management of member appeals coordinators, which can include the Commercial, Government, and Triage Units. In addition to the oversight of direct reports, the Manager is responsible for all activities related to:

  • Managing the appeals procedures and ensuring that appeals are resolved appropriately and that members are granted their rights, specifically to appeal non-coverage decisions made by the health plan.

  • Ensure that pertinent data regarding member grievances and appeals is captured and entered into the appropriate IT application, in compliance with the health plan, governmental and accrediting agency requirements.

  • Orient and train team members and ensure adequate staffing to handle volume of member calls and meet the performance metrics for the department.

Responsibilities

  • Effectively manages all member appeals for all membership types to ensure that Fallon Health members receive their right to appeal for all denials of service and coverage    

  • Process appeals/grievances as a backup, as needed

  • Acts as a senior resource person for the Appeals Coordinators and takes an active case load as necessary.  

  • Acts as primary first contact for escalated members   

  • Participates in interviewing, hiring, evaluating, counseling and terminating staff.    

  • Participates in various meetings as a department representative; acts as a representative on various company wide committees.

  • Orients new staff, serving as a preceptor and provides mentoring to new employees on an ongoing basis.

  • Collaborates with the Director to adjust assignments, as needed.    

  • Ensures adequate coverage to cover weeknights and weekends, answer telephones and meet performance standards.     

  • Conducts audits on a regular basis according to the policies and procedures as assigned by the Director.     

  • Dessimates policies and procedure information to staff to ensure successful functioning of the Department.   

  • Monitors staff performance and develops appropriate corrective action plans when necessary.

  • Identifies service issues and processes that impact member satisfaction and provides input to leadership about the issues.

  • Complies with HIPAA and Fallon Health confidentiality requirements for member information.

  • Performs regulatory reporting for the department.

  • Performs other responsibilities as assigned by Director  

Qualifications

Education: Bachelor’s Degree or equivalent experience in managed health care required

License: N/A

Certification: N/A

Experience: Minimum of 3-5 years’ experience in health care, managed care or insurance industry preferred. Preferred experience in Member Appeals

Job ID 5522

# Positions 1

Category Customer Service

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