Grievance/Appeals Representative II

Requires a HS diploma or equivalent
Minimum of 2 years’ experience in customer service, preferably in a managed care environment, medical office, or health insurance

Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
Contacts customers to gather information and communicate disposition of case; documents interactions.
Generates written correspondence to customers such as members, providers and regulatory agencies.
Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.
May make decision on administrative appeals where guidelines are well documented and involve limited discretion.
Prepares files for internal or external review by analysts, medical staff or outside consultant.
Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.

Certified Pharmacy Technician (CPhT) or related certification strongly preferred.
Minimum of 2 years of experience in healthcare or pharmacy services, with specific experience with pharmacy adjudication, prior authorizations, and appeals preferred.
Capacity to work autonomously as well as collaboratively within a team preferred.
Strong understanding of specialty medications and the pharmaceutical landscape preferred.
Excellent communication, organizational, and problem-solving skills preferred.
Familiarity with healthcare regulations and compliance, especially related to the 340B program preferred.
Proficient with healthcare software and technology used for managing prior authorizations preferred.