Supervisor, Appeals and Grievances

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 general direction of the Manager, Appeals and Grievances the Supervisor, Appeals and Grievances using in depth knowledge of Plan benefits and regulatory requirements, will coordinate and provide leadership for the daily operations of the Appeals and Grievances department. The supervisor represents the Appeals and Grievances Department and the Plan when working with review agencies (Office of Patient Protection / OPP), accreditation agencies (National Committee for Quality Assurance / NCQA and Centers for Medicare & Medicaid Services / CMS), providers, high profile employer groups (Group Insurance Commission / GIC and US Family Health Plan / USFHP). Internally, he/she is responsible for many cross department and divisional interfaces (i.e., advising case managers in the field, responding to requests from sales). The supervisor routinely deals with escalated issues, the supervisor must demonstrate strong professional judgment and apply risk management in highly escalated situations. The supervisor is also responsible for team management, individual analyst productivity, staff development, staffing and communication.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Provide oversight of the day-to-day operations of assigned team of Analysts and Coordinators and ensure all cases are processed timely.
• Work with Manager to ensure that employees have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities.
• Coach, develop, and mentor staff in the accurate and timely management of Appeals and Grievances.
• Partner with the Appeals and Grievances Program Management Team to ensure compliance.
• Ensure delivery of optimal customer services by working cross functionally with internal business units and external partners.
• Perform other duties and projects as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

Education

• Required (minimum): BA/BS or equivalent experience in health care, conflict resolution or related field
• Preferred:

Experience

• Required (minimum): 4–6 years of Appeals and Grievance experience.1-2 years of prior supervisor experience; health care benefit and regulatory knowledge of insurance products, policies, and procedures. Prior leadership experience required, including mentoring and developing associates to support their professional growth and team success.
• Preferred: None listed

Skill Requirements

• Strong ability to positively influence others and effectively drive change, fostering a supportive and constructive environment while implementing initiatives.
• Strong personal accountability and a commitment to fostering accountability within the team are essential for success in this role. You will be expected to take ownership of both individual and team performance, ensuring that goals are met, and challenges are addressed proactively.
• Must be highly organized and self-directed, with proven ability to work independently and in team settings.
• Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner.  Requires strong verbal and written skills to effectively communicate at both detail and summary levels to Point32Health management.
• Requires excellent interpersonal skills to communicate and work with staff of all skill and experience levels. Must be able to exercise patience and high level of diplomacy to recognize politically sensitive issues.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Must be able to manage a remote workforce.
• Work requires simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Weekend Coverage may be required on a rotating basis as regulated for line of business.
• Must be available to assist with mailing of member and provider documents, frequent travel will be required. This involves printing letters and dropping them off at UPS/USPS.
• Valid driver’s license and reliable transportation required.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

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.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact [email protected]