Meridian

  • Appeals & Grievance Coordinator

    Job Location US-MI-Detroit
    Job ID
    2018-6099
    Category
    Pharmacy
    Business Line
    MRx
  • Overview

    Who we are:

    MeridianRx is a full-service Pharmacy Benefit Manager (PBM) committed to driving down costs and elevating quality. Our clients experience better quality outcomes, thanks to effective clinical support, patient education, and specialty pharmacy programs.


    We work with a diverse range of clients, from members to healthcare providers to plan administrators. MeridianRx services clients across the country and our network continues to grow.


    Our employees work hard, play hard, and give back. MeridianRx employees enjoy: Happy hours, special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.

     

    A Day in the Life of a Appeals & Grievance Coordinator:

     

    This position works under the direction of the Department Director and Manager to provide and maintain reporting on all activities related to Appeals and Denials. This includes reports showing trending in appeals and denials, based on product, provider, reviewer and policy.  The position helps to develop and communicate technical specifications that are necessary to meet the regulatory, management, quality and clinical data needs. As necessary the position will also be responsible for providing operational support for the pharmacy department. This includes responding to internal and external requests for assistance with authorizations, medication profiles and other clinical and operational pharmacy processes.

    Responsibilities

    • Coordinates all appeals and denial requests
    • Ensure accurate data entry and tracking of provider and member requests
    • Collaborate with the client’s utilization review, case management, and member services staff to ensure appropriate resource allocation and utilization by all members
    • Act as a liaison representing MeridianRx
    • Request and maintain relevant client records, including medication prior authorizations, prior authorization appeals, reconsiderations, state fair hearings, and grievances.  Provide analysis and trending to the clients, where appropriate
    • Respond to requests for standard medication profiles/utilization reports as requested by client
    • Prepare quarterly status reports for the Pharmacy and Therapeutics Committee and Quality Improvement Committee
    • Provide support to client clinical and non-clinical departments to determine needs, resolve problems, improve processes and promote effective drug therapy
    • Take incoming/outgoing calls to assist members and providers with the appeals and grievances process
    • Document all appeal related requests from members and providers in the company database
    • Distribute all appeals related requests to the appropriate reviewer, notifying them of an urgent appeal
    • Ensure all appeals are reviewed and a decision is made within specified time frames
    • Coordinate all Level 2 Member appeals with Level 2 Member Appeals Committee and member. Develop informational review packets to be reviewed by Director of Clinical Operations and Level 2 Appeals Committee.
    • Track, trend, and report all appeals and appeal related requests to Director of Clinical Operations monthly
    • Support to ensure member notification is sent timely in accordance to contractual requirements
    • Refer all complex members to Health Plan of Michigan’s Case Management Department
    • Train new staff members on the appeals related processes
    • Coordinate with analysts, and upper management to maintain compliance of URAC standards
    • Assist with all Administrative Hearing Requests; Develop informational review packets to be review by pharmacist and Director of Clinical Operations
    • Assist with all OFIR requests
    • Assist in the collection of Healthcare Effectiveness Data and Information Set (HEDIS) data
    • Assist providers, members, and pharmacies to triage pharmacy questions
    • Assist in resolution of member issues related to pharmacy prescriptions
    • Processes state complaints, grievances and other CTM complaints that are received
    • Ensure compliance with all company, state and federal rules and regulations
    • Perform other duties as assigned
    •  

    Qualifications

    What you can bring to Meridian:

    • Bachelor’s degree in a health care related field is preferred
    • At least one year experience in a professional office environment and/or customer call center is required
    • Experience in a Managed Care environment is preferred
    •  Basic knowledge of drug products, dosage forms and usage, as well as retail pharmacy operations
    • Knowledge of medical and pharmaceutical terminology
    • Knowledge and/or experience in work teams
    • Understanding of NCQA, URAC or general accreditation requirements
    • Knowledge of CMS appeals process requirements
    • Excellent customer service and interpersonal communication skills; maintains professional demeanor
    • Computer/data entry skills; proficient in data warehouse, database, word processing and spreadsheet applications
    • Strong analytical skills
    • Detail-oriented with strong organizational skills
    • Telephone service skills
    • Ability to work with minimal management oversight on multiple projects with competing priorities
    • Ability to prioritize work and function under time constraints
    • Ability to work with confidential information
    • Ability and desire to work in a team atmosphere
    •  

     

    What Meridian can offer you:

    • Healthcare benefits that include a variety of plans, which are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • 401k matching that is above the national average.
    • Full-time MeridianRx employees are eligible for tuition reimbursement towards Bachelor’s or graduate degrees.
    • A bright and engaging company culture; the Meridian family of companies has been recognized as one of Metro Detroit’s Best and Brightest Companies to Work For 5 years in a row.

    Equal Opportunity Employer

    #MSTR

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