Member Appeals Specialist

Member Appeals Specialist

The role we are looking to fill would be focused on handling standard member appeals for pre-service pharmacy coverage for non-Medicare products, the turnaround times for these appeals is 30 calendar days (expedited turnaround time is 72 hours, but we start with standard appeals). The job requires use of our Appeals and Grievances system called Jiva (WellSense UM and CM are also working in this system). Member Appeals Specialist duties include:

• Case management of the appeal starting at assignment of the case from the AG Coordinator
• Evaluating timeliness of the appeal, eligibility of the member
• Issuing an acknowledgement letter using a template pre-loaded in the system of record, making edits necessary for the case at hand
• Reviewing the appeal request to determine if additional medical records are needed, and whether an Appointment of Rep form is needed
• Making any necessary verbal outreach to obtain documents / obtain answers to questions
• Collaborating with team members for case steps as needed / required by workflow (Specialists, Supervisor, Quality Nurses, Medical Directors, Pharmacy Team)
• Drafting appeal decision notices using template language and reference materials to ensure compliance
• Managing a case load of approximately 40 cases at a time and staying timely in accordance with our regulatory guidelines
• Use of our systems in processing work such as Pharmacy Benefit Management (PBM) with Client, Inc (Client), referring to Facets when necessary, Outlook for email, Teams for chat/meetings, Zoom for team meetings, Avaya for phone calls, etc.

We will provide training before assigning a small case load and monitor progress of the trainee, the right candidate will:

• Have member appeals experience (not provider claim appeals experience, though a combo of both member and provider is great!)
• Be comfortable with managing a case load in a system of record meant for managing appeals from start to finish
• Be responsive to emails and demonstrate proper email etiquette in general
• Be reliable and detail-oriented, engaged in the work and learning the work here at WellSense
• Be enthusiastic about learning how to use the reference materials we have developed to ensure consistency and compliance
• Enjoy reaching out to team mates for questions and support in a 100% virtual setting