Appeals Coordinator, Medicare Part D
Arizona, Rhode Island
Job DescriptionExecutes 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
TitleAppeals Coordinator, Medicare Part D
Job FamilyPharmacy Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date10/3/2019
Date Requisition Created10/3/2019
Work ExperienceMedicare Part D (MedD), Pharmacy
License and Certifications - RequiredCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
License and Certifications - Preferred
Other Job Requirements
- 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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