Member Appeals Specialist

Job Summary

A company is looking for a Member Appeals Specialist (Remote).

Key Responsibilities

• Triage and assign incoming member appeals and grievances; manage daily email and voicemail queues
• Evaluate appeal eligibility, timeliness, and completeness of submitted documentation
• Prepare and issue acknowledgement and decision letters using system templates

Required Qualifications

• Prior experience managing member appeals (pharmacy or medical); knowledge of pre-service coverage preferred
• Proficient in case management systems such as Jiva, and familiar with PBM tools (ESI), Facets, Outlook, and Teams
• Strong organizational skills with proven reliability in remote work
• Clear, professional communication and email etiquette; responsive and proactive follow-up
• Team-oriented mindset with a commitment to learning, compliance, and quality improvement