Member Appeals Specialist

Job Title: Member Appeals Specialist
Job Location: Remote, MA
Job Duration: 2-3 Months (possibility of extension)
Payrate: $20 - $22/ hr on w2

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Job Summary:

• Primary responsibilities would include triaging incoming appeals / grievances, categorizing them appropriately, assigning them to the team, making outbound calls when necessary.
• Also checking voicemails, responding to emails/ voicemails.
• 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 (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 Well Sense.
• Be enthusiastic about learning how to use the reference materials we have developed to ensure consistency and compliance.
• Product reaching out to team mates for questions and support in a 100% virtual setting.