Returning Candidate? Log back in! Coordinator, Grievance and Appeals Location US- ID 2025-4166 Category Administration Position Type Full-Time Remote Yes Company Navitus About Us Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other. Pay Range USD $19.60 - USD $23.06 /Hr. Work Schedule Description (e.g. M-F 8am to 5pm) M-F 8am to 5pm Remote Work Notification ATTENTION: We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming. Overview

Navitus Health Solutions is seeking a Grievance and Appeals Coordinator to join our team!

 

The Navitus Grievance and Appeals process is an essential function to Navitus’ compliance with CMS regulations, accrediting body standards, other applicable regulatory requirements, and member expectations. The Navitus Grievance and Appeals department serves as the central repository for all complaints received by Navitus and all appeal requests where the responsibility has been delegated to Navitus. The Navitus Grievance & Appeals Coordinator serves to administrate the Navitus Grievance and Appeals processes as outlined by Client/Plan Sponsors, departmental policies and procedures, and regulatory standards. Coordinator, Grievance and Appeals serves as a liaison for Navitus members, prescribers and pharmacies regarding complaints or appeals related to denied pharmacy claims, membership and benefit issues, reimbursements and quality of care or service. Coordinator, Grievance and Appeals is responsible for presentation of the member appeals as required to the Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, Client, and/or the contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies, and standards.

 

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team? 

Administrate Standard and Expedited Appeals Processes as outlined in Client/Plan Sponsor Member Handbook and in compliance with applicable accrediting body standards, CMS and other state or federal regulatory requirements. Strict adherence to turn-around time and quality of documentation standards established in accordance with regulatory standards is required.Act as the primary investigator and contact person for member, prescriber or pharmacy grievances and appeals, which includes sending the appropriate acknowledgement of the grievance/appeal per policy, educating the member and/or member representative about the grievance/appeal, gathering all pertinent and relevant information regarding the grievance/appeal, notifying the appropriate parties of the resolution per policy and ensuring that all internal processes are completed to resolve the issueGather and provide documentation and research outcomes within required timeframes to Clients/Plan Sponsors who manage their own appealsThoroughly document all action taken on behalf of the member to resolve the grievance/appealPrepare and deliver statistics for required reportingParticipate in audits, including document preparation and participation in on-site or remote audits, as a subject matter expertAbiding by HIPAA regulations and confidentiality requirements; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or other department staffEducate and monitor compliance with complaint and appeal procedures in such departments as the call center and prior authorizationAudit and provide oversight of upstream and downstream processes impacting complaints and appealsOther duties as assigned Qualifications

What our team expects from you?

High School Diploma or equivalent required. 2 years post high school education or bachelor’s degree preferred. CPhT certification or ability to obtain desired and preferred2-3 years of managed care and/or insurance background in addition to a strong knowledge of CMS coverage determination and redetermination processes preferredExperience with CMS and/or NCQA audits strongly desiredProven success in documenting case files and managing multiple cases within requires timeframes desiredParticipate in, adhere to, and support compliance program objectivesThe ability to consistently interact cooperatively and respectfully with other employeesWhat can you expect from Navitus?      • Top of the industry benefits for Health, Dental, and Vision insurance      • 20 days paid time off      • 4 weeks paid parental leave      • 9 paid holidays      • 401K company match of up to 5% - No vesting requirement      • Adoption Assistance Program      • Flexible Spending Account  #LI-Remote

 

We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

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