Member Appeals Specialist

Job Title

Pay Rate: $18 to $24 per hour

Summary:

Work Mode: Remote

Responsibilities:

Triage incoming appeals and grievances, categorize them appropriately, and assign them to the team.

Make outbound calls when necessary and check voicemails.

Respond to emails and voicemails.

Handle standard member appeals for pre-service pharmacy coverage for non-Medicare products with a 30-day turnaround time.

Use the Appeals and Grievances system called Jiva.

Manage case assignments from the AG Coordinator.

Evaluate the timeliness of appeals and member eligibility.

Issue acknowledgement letters using system templates, making necessary edits.

Review appeal requests to determine if additional medical records or an Appointment of Rep form is needed.

Conduct verbal outreach to obtain documents or answers to questions.

Collaborate with team members as required by workflow.

Draft appeal decision notices using template language and reference materials to ensure compliance.

Manage a caseload of approximately 40 cases and adhere to regulatory guidelines.

Utilize systems such as Pharmacy Benefit Management (PBM), Facets, Outlook, Teams, Zoom, and Avaya for processing work.

Requirements:

Experience in member appeals (experience in provider claim appeals is also beneficial).

Comfortable managing a caseload in a system of record.

Responsive to emails and demonstrates proper email etiquette.

Reliable, detail-oriented, and engaged in learning.

Enthusiastic about using reference materials to ensure consistency and compliance.

Able to work in a 100% virtual setting.

Preferred Skills:

Experience in both member and provider appeals is advantageous.

Benefits:

Training provided before assigning a small caseload.

Opportunity to work remotely.