Member Appeals Specialist

• We are seeking a detail-oriented and reliable Member Appeals Specialist to join our team on a contract basis.
• This role is responsible for triaging incoming member appeals and grievances, managing case assignments, and ensuring timely resolution in compliance with regulatory requirements.
• The ideal candidate will have prior experience handling member appeals (not just provider claim appeals), strong communication skills, and the ability to thrive in a 100% remote work environment.

• Triage, categorize, and assign incoming appeals and grievances to the appropriate workflow.
• Review appeal requests for timeliness, eligibility, and required documentation (e.g., medical records, Appointment of Representative forms).
• Draft and issue acknowledgment letters and decision notices using system templates, tailoring as needed.
• Conduct outreach to members, providers, or stakeholders to gather missing information or clarify case details.
• Collaborate with internal teams, including Supervisors, Quality Nurses, Medical Directors, and the Pharmacy team, to resolve cases effectively.
• Ensure accuracy, compliance, and professionalism in all written and verbal communications.
• Actively participate in training, apply reference materials, and maintain responsiveness in a fully remote setting.

• Prior experience in member appeals case management (provider appeals experience is a plus).
• Strong organizational skills and the ability to manage multiple cases simultaneously.
• Excellent written and verbal communication skills, including email etiquette.
• Detail-oriented, dependable, and proactive in seeking guidance and collaborating with team members.
• Comfortable working independently in a virtual environment with various case management tools.

Experince Required - 

• Manage a case load of ~40 active appeals, ensuring compliance with standard (30 days) and expedited (72 hours) turnaround times.
• Utilize systems such as Jiva (Appeals & Grievances system), PBM, Facets, Outlook, Teams, Zoom, and Avaya to process cases and manage communication.