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Member Appeals Specialist

Remote:

Full Remote

Contract:

Fixed term

Experience:

Mid-level (2-5 years)

Work from:

Massachusetts (USA), United States

Offer summary

Qualifications:

Experience with member appeals required, Familiarity with case management systems, Proficiency in formal email communication, Detail-oriented and reliable, Willingness to learn about compliance.

Key responsabilities:

Manage appeal cases and timelines
Communicate with members for document needs
Collaborate with team on case processing
Draft compliant appeal decision notices
Utilize various software for workflow management

ICONMA Human Resources, Staffing & Recruiting Large https://www.iconma.com/

1001 - 5000 Employees

See more ICONMA offers

Job description

Member Appeals Specialist

Location: Remote
Duration: 4 Months

Description:
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 Express Scripts, Inc (ESI), 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

The job requires use of our Appeals and Grievances system called Jiva (WellSense UM and CM are also working in this system),

As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, gender, sexual orientation, gender identity or express, ethnicity, national origin, age, disability status, political affiliation, genetics, marital status, protected veteran status, or any other characteristic protected by federal, state, or local laws.