Member Appeals Specialist

Job Summary

To support a remote team, the full-time Member Appeals Specialist will manage member appeals related to pre-service pharmacy coverage for non-Medicare health plans, overseeing the process from intake through final resolution while ensuring compliance with regulatory timelines.

Key Responsibilities

• Triage and categorize incoming member appeals and grievances
• Assign and manage appeals from intake through final resolution
• Maintain a caseload of approximately 40 active appeals

Required Qualifications

• Previous member appeals experience with a health plan or insurance payer
• Experience managing appeals from start to finish within an appeals management or case management system
• Strong attention to detail and organizational skills
• Ability to manage multiple priorities and meet strict regulatory deadlines
• Comfortable working independently in a fully remote environment