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We are seeking a dedicated Medical Appeals Specialist to manage standard member appeals for pre-service pharmacy coverage for non-Medicare products. The ideal candidate will ensure timely resolution of appeals, adhering to a standard turnaround time of 30 calendar days (with expedited requests requiring a turnaround of 72 hours). This role involves utilizing our Appeals and Grievances system, Jiva, in collaboration with other teams to provide exceptional service to our members.
This is a remote position.
Medical Appeals Specialist Responsibilities
Manage the appeal case from assignment by the Appeals and Grievances Coordinator.
Evaluate the timeliness and eligibility of appeals.
Issue acknowledgement letters using pre-loaded templates, making necessary edits for individual cases.
Review appeal requests to identify the need for additional medical records or an Appointment of Representative form.
Conduct verbal outreach to gather documents or clarify questions.
Collaborate with team members, including Specialists, Supervisors, Quality Nurses, Medical Directors, and the Pharmacy Team, to navigate case steps.
Draft appeal decision notices using template language and reference materials to ensure compliance with regulations.
Maintain a caseload of approximately 40 cases, ensuring timely processing in line with regulatory guidelines.
Utilize various systems and tools for processing work, including Pharmacy Benefit Management (PBM) with Express Scripts, Inc. (ESI), Facets, Outlook, Teams, Zoom, and Avaya.
Medical Appeals Specialist Qualifications
Previous experience in member appeals (experience with provider claim appeals is a plus, but not required).
Proficient in managing a caseload using a system of record designed for appeals.
Strong communication skills, with a focus on responsiveness and email etiquette.
Detail-oriented and reliable, with a proactive approach to learning and engaging with the work.
Enthusiastic about utilizing reference materials to ensure consistency and compliance.
Comfortable reaching out to team members for support in a fully virtual environment.