Job Description
Job Description
Job Title: Member Appeals Specialist
Location: Charlestown, MA (Fully Remote)
Pay Rate- $20/hr. - $23/hr.
Duration- 3 months+ possible extension
Shift: 9:00 AM – 5:00 PM, Monday to Friday
Job Duties
- Case management of the appeal starts at the assignment of the case from the AG Coordinator, evaluating the timeliness of the appeal, eligibility of the member, issuing an acknowledgement letter using a template pre-loaded in the system of record, and 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.
Pride Global offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), a 401(k)-retirement savings, life & disability insurance, an employee assistance program, identity theft protection, legal support, auto and home insurance, pet insurance, and employee discounts with some preferred vendors.
As a certified minority-owned business, Pride Global and its affiliates - including Russell Tobin, Pride Health, and Pride Now - are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, disability, age, veteran status, or other characteristics.
Company DescriptionPride Health is Pride Global's healthcare staffing branch, providing recruitment solutions for healthcare professionals and the industry at large since 2010.
Company Description
Pride Health is Pride Global's healthcare staffing branch, providing recruitment solutions for healthcare professionals and the industry at large since 2010.