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Member Appeals Specialist

Trillium Professional is now seeking a Member Appeals Specialist for a 100% remote position!

Candidates will work Monday-Friday, 40 hours/week for about 13 weeks. Pay rate is $24.79/hour.

Member Appeals Specialist to manage member appeals related to pre-service pharmacy coverage for non-Medicare health plans. This is a fully remote case management position where you’ll independently manage appeals from intake through final resolution while ensuring compliance with regulatory timelines.

Candidates may reside in most U.S. states. Excluded states: Arkansas, California, Delaware, Hawaii, Iowa, Louisiana, Mississippi, Montana, Nebraska, North Dakota, South Dakota, and Wyoming.

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.
-Review appeals for timeliness, member eligibility, and required documentation.
-Prepare acknowledgment letters and appeal decision notices using approved templates.
-Contact members or authorized representatives to obtain additional information or documentation.
-Collaborate with supervisors, quality nurses, medical directors, pharmacy staff, and other team members throughout the appeals process.
-Respond promptly to emails, voicemails, and member inquiries.
-Meet all regulatory turnaround requirements (30 calendar days for standard appeals; 72 hours for expedited appeals).
Systems & Tools

Apply now!

Experience with the following is preferred:
-Jiva (Appeals & Grievances system)
-Express Scripts (PBM)
-Facets
-Microsoft Outlook
-Microsoft Teams
-Zoom
-Avaya

Required Qualifications
-Previous member appeals experience with a health plan or insurance payer (provider claims appeals alone are not sufficient; experience with both member and provider appeals is a plus).
-Experience managing appeals from start to finish within an appeals management or case management system.
-Strong attention to detail and organizational skills.
-Excellent written and verbal communication.
-Ability to manage multiple priorities and meet strict regulatory deadlines.
-Comfortable working independently in a fully remote environment.
Training
-Company provides comprehensive onboarding and training before assigning a smaller caseload, with continued coaching and support as responsibilities increase.

Ideal Background
Strong candidates will have experience in:
-Member Appeals
-Appeals & Grievances
-Utilization Management Appeals
-Pharmacy Appeals
-Health Plan Case Management
-Managed Care Operations

Trillium has been recruiting and placing clerical and office professionals for over 30 years. From Fortune 100 companies to small businesses, our philosophy remains the same: to achieve excellence by providing quality employees with an uncompromising level of service. We believe in honesty, integrity, and a simple philosophy of providing value to our customers and our employees. We strive to be unsurpassed in the recruitment and placement of professionals. Trillium is an Equal Opportunity Employer.

By applying to this job, I agree to receive electronic communications including SMS text and email regarding future opportunities, referral bonus incentives, and other promotions from Trillium. You may opt out at any time from future communications by responding STOP to any electronic communication. You may view our full privacy policy at https://trilliumstaffing.com/jobs/privacy/.

Trillium offers a comprehensive benefit package that includes the ability to participate in health insurance and retirement plans, paid holidays, state required leave, and other leave, if applicable. Trillium’s offerings are dependent on the state in which the assignment is located, length of time worked, and may change depending on assignment. Benefit packages for direct hire placements vary based on the client company.

 

Contact Us if you have any questions

Our intentions are to fill job vacancies as quickly as possible with qualified candidates. We are always accepting applications if a time sensitive job has an application deadline it is noted in the job description. Click on "Apply" to begin the apply process.