Appeals Coordinator, Medicare Part D

Arizona, Rhode Island

Job Description

Executes the Coverage Determination (CD) reconsideration process in accordance with CMS guidelines for Magellan Rx Management’s PDP and all Health Plan / clients covering Medicare Part D enrollees. Prepares and delivers the CD case files for submission to the Independent Review Entity (IRE). Responds to Independent Review Entity (IRE) appeals within required time frames. Oversees IRE resource work product on weekends, evenings and holidays. Supports IRE submission and appeals processing across multiple business lines: All MRx Medicare Part D Clients that delegate Auto-forwards, Reconsiderations, and ALJ requests.
  • Monitors IRE fax queue for new incoming IRE cases (i.e. Reconsideration and IRE Re-openings). Reviews cases for adjudication. Effectuates favorable decisions in appropriate systems.
  • Processes out-of-compliance (OOC) CDs as auto-forwards to the IRE. Researches and creates complete case file. Documents all IRE cases and maintains records. Tracks IRE cases using tracking forms compliant with CMS standards. Continually looks for opportunities to improve tracking form information, preparation and automation.
  • Attends Contact Center, Clinical Pharmacist and Medicare Part D and Compliance meetings, as needed, to support IRE/Appeals process.
  • Assists with Clinical Program outreach and/or Prior Authorization processing during peak periods.
  • Reviews multiple reports daily to monitor compliance.
  • Works cross functionally with multiple teams to help improve quality and compliance.

General Job Information

Title

Appeals Coordinator, Medicare Part D

Grade

18

Job Family

Pharmacy Group

Country

United States of America

FLSA Status

United States of America (Non-Exempt)

Recruiting Start Date

10/3/2019

Date Requisition Created

10/3/2019

Work Experience

Medicare Part D (MedD), Pharmacy

Education

Associates, Bachelors

License and Certifications - Required

CPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy

License and Certifications - Preferred

Other Job Requirements

Responsibilities

  • Ability to identify various Coverage Determination processing issues in compliance with CMS regulations and corporate policies.
  • Excellent research and analytical skills.
  • Ability to work under tight deadlines.
  • Self-starter and strong attention to detail.
  • Highly organized with excellent written and verbal communication skills.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

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