Appeals & Grievance Specialist - Pharmacy - Remote

Why This Role is Important to Us

Appeals and Grievances Representative - Pharmacy supports the Operations Department and the Appeals and Grievances team in a number of ways to ensure compliance on activities related to member complaints in the organization and improve the member experience. This position works collaboratively across many departments at Commonwealth Care Alliance (CCA) as well as externally to facilitate timely resolution of all grievances and appeals and ensures compliance with regulations. Additionally, this position is responsible for timely investigation and member outreach as well as supports the Appeal and Grievances team in creation, review and mailing of member communication related to appeal and grievances.  This position will also encompass the role of Pharmacy Appeal Intake Specialist.

What You'll Be Doing

• Processing of Grievances & Pharmacy Appeals: - Responsible for the progress of grievance and appeal intervention and resolution.
• Assure verbal and written responses are provided to members and/or other parties within the required timeframes.
• Assure timely completion of member verbal and written correspondence.
• Thoroughly document all member appeal and grievance related interactions and interventions into CCA database.
• Member Outreach: - Provide accurate, prompt, and courteous service in response to written and telephonic member complaints.
• Responsible for communication and member outreach related to the member complaint.
• Support creation, review, and mailing of notices to members to ensure prompt and courteous member communication and that the organization is compliant and meeting all strict deadlines.
• When necessary collaborate with care teams, clinical staff, family members, and other involved in providing care for our members.
• Interdisciplinary Communication and Collaboration: - Communicate and work collaboratively with CCA departments to help manage and resolve member appeals and grievances.
• CCA departments to help manage and resolve member appeals and grievances.
• Act as a liaison between multiple departments to ensure the timely and complete capture and processing of all grievances and appeals.
• Interdepartmental stakeholders include but are not limited to: quality; regulatory affairs/compliance; clinical, operations, pharmacy, dental, reporting, and member services.
• Supports the Senior Appeals & Grievance Coordinator and A/G Coordinator in day-to-day tasks and assignments.
• Content Expert: - Act as CCA's content expert on State and Federal Grievance and Appeal regulations for all CCA products.
• Appropriately interpret, apply, and communicate CMS and State regulations. Remain apprised of policy updates and update operational processes. Complaints Monitoring: - Supports daily monitoring of Medicare and EOHHS's Complaints Tracking & Management (CTM) Module and timely communication of next steps on complaints notification, intervention, and resolution. Pharmacy Appeal Intake Specialist:
• Perform intake, processing and completion of pharmacy redetermintions (appeals)
• Take necessary steps to perform a complete and accurate evaluation of non-formulary drug exception requests prior to approval, authorization or claim override.
• Plan, prioritize, organize and complete work to meet established and required regulatory timeframes.
• Research appeal requests in multiple computer applications, including PBM systems, to obtain information that may impact review
• Contact prescribers to obtain additional clinical information or medical records when necessary
• Document all authorizations and denials completely and accurately, and in accordance with letters/timelines as defined by state and federal regulations to ensure appropriate notification to prescribing physician and impacted member
• Effectuate overturned pharmacy appeals in PBM system
• Develop job aids, workflows, and document structure in partnership with medical and pharmacy teams.
• Collect all pharmacy data/information and provide quality assurance review as required to support regulatory audits (e.g. CDAG)  

What We're Looking For

• Education Required: - Pharmacy Technician Licensure or Certification as required by Massachusetts law. Bachelor's degree (B.S. or B.A.) or and associates degree with equivalent of at least one year of previous professional experience in healthcare, case/care management, administrative or related position. Certified Pharmacy Technician (CPhT) preferred
• Minimum Experience Required:  - 1 year of experience in a CMS regulated Appeals and Grievance function.
• Must be a self-starter with a high degree of accountability and responsibility.
• Commitment of the mission of the organization.
• Exceptional attention to detail.
• Ability to research regulations and guidelines and adapt to print materials.
• Ability to effectively work independently or collaboratively with others.
• Excellent written/verbal communication and interpersonal skills.
• Exceptional organizational skills.
• Demonstrates excellent judgment.
• Ability to meet strict, time sensitive deadlines.
• Must be proficient with Microsoft Office, including intermediate level of Excel and Word or higher.
• Fluency in Spanish preferred  

Actual Work Location, Boston, Massachusetts 02108
All LocationsBoston, MA; Hybrid
Exempt / Not ExemptNon-Exempt