Member Appeals Specialist in Charlestown, Massachusetts - #67081 | VanderHouwen

Description

Job Id: 67081

Member Appeals Specialist
Our client is seeking a Member Appeals Specialist to join their team and handle standard member appeals for pre-service pharmacy coverage for non-Medicare products. This role focuses on managing appeals with a turnaround time of 30 calendar days, with the ability to expedite to 72 hours when required. The ideal candidate will be detail-oriented, highly organized, and comfortable working in a 100% virtual environment, utilizing the Appeals and Grievances system called Jiva to ensure regulatory compliance and efficiency.

This role is fully remote.

Member Appeals Specialist Responsibilities

• Manage case assignments from the Appeals and Grievances Coordinator.
• Evaluate the timeliness of appeals and eligibility of the member.
• Issue acknowledgment letters using pre-loaded templates, making necessary edits based on the specific case.
• Review appeal requests to determine if additional medical records or an Appointment of Representative form is required.
• Conduct verbal outreach to obtain necessary documents or answer questions.
• Collaborate with team members (Specialists, Supervisors, Quality Nurses, Medical Directors, Pharmacy Team) to ensure smooth workflow processes.
• Draft appeal decision notices using template language and reference materials for compliance.
• Handle a caseload of approximately 40 cases, maintaining timely processing per regulatory guidelines.
• Utilize various systems, including Pharmacy Benefit Management (PBM) with Express Scripts, Inc (ESI), Facets, Outlook, Teams, Zoom, and Avaya, to process and communicate work efficiently.

Member Appeals Specialist Qualifications

• Previous experience in managing member appeals (experience with both member and provider appeals is a plus).
• Proficiency in handling caseloads in systems designed for end-to-end appeal management.
• Strong communication skills, including responsiveness to emails and proper email etiquette.
• Detail-oriented and engaged in the work with a commitment to learning and growth.
• Enthusiasm for using reference materials to ensure compliance and consistency.
• Ability to thrive in a collaborative, virtual team environment, actively seeking support and guidance when needed.

Compensation: $18-$22/hr. (DOE)

VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

Meet VanderHouwen
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VanderHouwen is an award-winning, Women & Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!

VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.

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