Appeals Coordinator

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title

Appeals CoordinatorJob Description

• Maintains a caseload and monitors day to day compliance of appeal decision time frames. 
• Reviews clinical and medical records for completeness and determines administrative or clinical appeal.
• Assigns reviews to physician advisers and medical directors for those requiring medical necessity reviews.
• Enters all data related to appeals and case reviews into a database.
• Prepares and presents information on appeals to panels second-level multi-disciplinary committee.
• Participates in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provides new employee training, monitors QI (Quality Improvement) activities of appeals department, and assists in the development of depart flows and implementations. 
• Coordinates and distributes first, second and third level appeal request assignments.
• Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
• Responds to member, provider, and client telephone inquiries regarding status, process and outcome of appeals.
• Organizes volume of work and work-flow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed.

Minimum Qualifications:

• 4 years of Customer Service experience
• Must have an active pharmacy technician license/registration and national certification (e.g., PTCB or ExCPT)
• Must have a high school diploma or GED

Potential pay for this position ranges from $21.15 - $31.73 based on experience and skills. Pay range may vary by 8% depending on applicant location.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, creed, color, religion, gender, sexual orientation, gender identity/expression, national origin, disability, age, genetic information, veteran status, marital status, pregnancy or related condition (including breastfeeding), expecting or parents-to-be, or any other basis protected by law. 

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.