Appeal Analyst Pharmacy Medicare
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![]() United States, Michigan, Grand Rapids | |
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Job Summary
Effectively administer all steps of the Pharmacy appeal and review processes for all Medicare products in a pleasant and expedient manner to ensure quality customer service and compliance with all legislative, regulatory and accreditation requirements. Assist customers and staff throughout the process by providing complete information and follow up on a timely basis. Ensure favorable decisions are properly effectuated. Assist the Lead and/or Supervisor in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. Responsible for the analysis, research and completion of complex member appeal investigations. Effectively administer all steps of the member appeal and ALJ hearing processes for all Medicare products to thoroughly investigate appeal requests, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible. Ensure compliance with all mandated, legislative, regulatory and accreditation requirements. Assist customers and staff throughout the process by providing complete information and follow up on a timely basis. Ensure committee, State and Federal decisions are properly implemented. Assist the Lead, Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. Essential Functions
Required
Preferred
As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
Primary Location SITE - Priority Health - 1231 E Beltline - Grand RapidsDepartment Name PH - Clinical Pharmacy - Government ProductsEmployment Type Full timeShift Day (United States of America)Weekly Scheduled Hours 40Hours of Work 8:00 a.m. to 5:00 p.m.Days Worked Monday to FridayWeekend Frequency On-call weekendsCURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447. |