Appeals & Grievances Coordinator

Company Overview:

Join us in our mission to transform healthcare! RxAdvance, now doing business as nirvanaHealth, is committed to bringing the art of possible to the payer and PBM industries, which is why we strive to invest in our employees throughout all stages of life. Success radiates through all levels of employees here, with competitive benefits, a strong focus on employee wellness, and optional education courses offered through UDEMY: we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria – the first robotic process automation cloud platform designed for healthcare.

Led by our chairperson John Sculley (former Apple CEO) and noted healthcare entrepreneur and founder of ikaSystems Ravi Ika, nirvanaHealth endeavors to sizably reduce the $900 billion in waste in healthcare administrative and medical costs. We are seeking A-players to join our team – folks who embrace the grind and hustle of a growing company, are collaborative and innovate, are life-long learners and growers, and have an entrepreneurial and positive mindset.

Job Summary:

The Appeals & Grievances Coordinator organizes and assists daily clinical operations within the organization. These operations are primarily focused on appeals and grievances, utilization management, and communications. They work closely with stakeholders to manage daily clinical operations, scope, and quality to meet established service level agreements. This individual works with team members, such as pharmacists, nurses, and pharmacy technicians, to ensure that clinical activities are completed according to accreditation and regulatory requirements.

Job Responsibilities (but not limited to):

• Receives inbound calls, faxes, emails, and mail to initiate an appeal, grievance, or prior authorization request.
• Makes outbound calls to obtain additional information pertaining to an appeal, grievance, or prior authorization request.
• Collects, organizes, and tracks information received from a variety of resources to facilitate and expedite the processing of requests.
• Generates applicable letters for members and providers in accordance with accreditation and regulatory standards.
• Assists with business operations in the development of communications (e.g., letters, forms) and configuration within the platforms in compliance with state and federal requirements.
• Assists with compiling statistical data, reporting, and analyses to demonstrate clinical, financial, and operational effectiveness and quality.
• Provides support for internal and external audits and surveys.
• Maintains privacy and confidentiality in all interactions.
• Follows all state and federal regulations applicable to clinical operations and utilization management.
• Stays abreast of new regulations to ensure regulatory compliance applicable to clinical operations.
• Meets established productivity and quality standards.
• This position has the ability to engage in on-call weekend work.
• Performs other duties as assigned.

Qualifications:

Education and/or Training:

• Bachelor’s degree in public policy or a healthcare related field is preferred; equivalent work experience in related field is acceptable.

Professional Experience:

• At least 2 years relevant experience within a health plan, managed care organization, or third-party administrator is preferred.
• Experience with appeals and grievances and/or prior authorization processes is preferred.
• Experience with Medicare Advantage plans with knowledge of CMS guidance/regulations is preferred.
• Must have a regard for confidential data and adherence to corporate compliance policy.

Specialized Skills:

• Highly developed oral/written communication skills, self-motivation, and ability to work independently with minimal supervision are necessary.
• Strong organizational skills and attention to detail.
• Must be flexible and able to constantly review and reset priorities, often daily, and to handle multiple tasks/projects simultaneously.
• Team player with a collaborative working style.
• Strong interest in healthcare and technology industries.