Avaya Software, Case Management, Compensation and Benefits, Detail Oriented, Healthcare Quality, Maintain Compliance, Medical Records, Medicare, Microsoft Outlook, Nursing, Organizational Skills, Pharmacy, Regulations
Pay Rate: $18 to $24/hr
Summary:
Responsibilities:
- Triaging incoming appeals and grievances, categorizing them appropriately, and assigning them to the team.
- Making outbound calls when necessary, checking voicemails, and responding to emails/voicemails.
- Handling standard member appeals for pre-service pharmacy coverage for non-Medicare products.
- Managing case load of approximately 40 cases at a time while adhering to regulatory guidelines.
- Using the Appeals and Grievances system, Jiva, to process cases.
- Case management starting from assignment by the AG Coordinator.
- Evaluating timeliness of the appeal and eligibility of the member.
- Issuing acknowledgment letters using pre-loaded templates and making necessary edits.
- Reviewing appeal requests to determine if additional medical records or Appointment of Rep forms are required.
- Collaborating with team members such as Specialists, Supervisors, Quality Nurses, Medical Directors, and Pharmacy Team.
- Drafting appeal decision notices using template language and reference materials to ensure compliance.
- Utilizing systems like Pharmacy Benefit Management, Facets, Outlook, Teams, Zoom, and Avaya for processing work.
Requirements:
- Experience in member appeals (not provider claim appeals).
- Comfort with managing a case load in a system designed for appeals management.
- Reliability and attention to detail.
- Responsiveness to emails and proper email etiquette.
- Enthusiasm for learning and using reference materials for consistency and compliance.
- Ability to work in a virtual setting and reach out to team members for support.
Location:
- Open to candidates from a variety of states including Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin.
A
Axelon Services Corporation