Job Summary Effectively administer all steps of the Pharmacy appeal and review processes for all Medicare products in a pleasant and expedient manner to ensure quality customer service and compliance with all legislative, regulatory and accreditation requirements. Assist customers and staff throughout the process by providing complete information and follow up on a timely basis. Ensure favorable decisions are properly effectuated. Assist the Lead and/or Supervisor in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. Responsible for the analysis, research and completion of complex member appeal investigations. Effectively administer all steps of the member appeal and ALJ hearing processes for all Medicare products to thoroughly investigate appeal requests, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible. Ensure compliance with all mandated, legislative, regulatory and accreditation requirements. Assist customers and staff throughout the process by providing complete information and follow up on a timely basis. Ensure committee, State and Federal decisions are properly implemented. Assist the Lead, Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. Essential Functions + Track all activity including communication for each appeal case by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to timeline requirements. + Complete investigation of Medicare Pharmacy appeals, including formulate action steps, gather information, ensure benefits are interpreted accurately and consistently, prepare the appeal case with facts to present to the appropriate parties (clinical pharmacists, medical director, IRE, ALJ, etc.). Ensure all case files are complete, organized, and meet State, Federal, Health Plan and NCQA requirements. + Audit case files to ensure they are complete, organized and secure an ensure all procedures are followed and timeline requirements are met, including effectuation of favorable decisions. + Complete the investigation of requests for hearing with the ALJ (Administrative Law Judge); gather relevant information and prepare comprehensive documentation as evidence for the ALJ. + Represent Priority Health during the ALJ hearings with the member and the judge. Present facts and evidence in a courteous and professional manner. + Performs other duties as assigned. + Responsible for complex and thorough investigation of appeals, external complaints, and fair hearing reviews including formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the appeal request (external medical records, internal documentation from enterprise-wide systems). + Evaluate information gathered to ensure all benefit language outlined in plan documents have been interpreted accurately and consistently, determine if pharmacy and medical policies have been applied appropriately or if additional clinical information is available after the original decision + Support root cause analysis to determine corrective actions related to the appeals process by researching system issues to determine course corrections + Apply strong analytical skills and business knowledge to investigation, analysis and recommendation of solutions to problems + Communicates, collaborates and acts as a consultant to internal and external customers in order to resolve complex issues + Support the lead for expedited requests, gathering relevant information, working with Medical Director to determine if criteria is met. If expedited criteria is met, ensure investigation, review, decision, and completion within required 72 hour time line. Communicate outcome to member. + Provide education and communicates training needs to Customer Service Leadership, when appropriate, to avoid unnecessary appeals and/or expedited requests. + Track all activity including communication for each appeal case by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to time line requirements and to ensure all regulatory reporting requirements are met. + Collaborate with cross-functional departments to implement improvements to member experience, medical policies, legal documents, member materials, departmental processes and workflow. Qualifications Required + Associate's Degree or equivalent + 2 years of relevant experience in Customer Service, claims, Legal and/or enrollment/eligibility Preferred + Bachelor's Degree or equivalent + 2 Years of experience in a Pharmacy Call Center + Working knowledge of Priority Health systems for claims payment, care management, authorizations, customer service interactions, pharmacy Rx profiles, medical policies and plan documents for Medicare product lines + 2 years of relevant experience Extensive knowledge of CMS regulations and process + Previous experience with grievance and appeals processes About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence. How Corewell Health cares for you + Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here (https://careers.corewellhealth.org/us/en/benefits-new) . + On-demand pay program powered by Payactiv + Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! + Optional identity theft protection, home and auto insurance, pet insurance + Traditional and Roth retirement options with service contribution and match savings + Eligibility for benefits is determined by employment type and status Primary Location SITE - Priority Health - 1231 E Beltline - Grand Rapids Department Name PH - Clinical Pharmacy - Government Products Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 8:00 a.m. to 5:00 p.m. Days Worked Monday to Friday Weekend Frequency On-call weekends CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.