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Appeals Technician
About Us:
Judi Health is a health technology company offering a wide range of benefits administration solutions for employers and health plans. This includes Capital Rx, a public benefit corporation that provides full-service pharmacy benefit management (PBM) solutions to self-insured employers; Judi Health™, which offers comprehensive health benefit management solutions for employers, TPAs, and health plans; and Judi®, the industry’s leading proprietary Enterprise Health Platform. To learn more, visit www.judi.health.
Position Summary:
Responsible for taking incoming requests for first, second level and external appeals while ensuring high level of customer service and maximizing productivity. Work with appeals team for multiple lines of business such as Commercial, Exchange and Medicare, ensuring the proper submission of appeals for review by pharmacist and medical directors.
Position Responsibilities:
- Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
- Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
- Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
- Review all cases received, to verify if case meets qualifications for appeal review.
- Performs triple check to ensure quality reviews and handling in accordance with policies and procedures.
- Updates case types, sends appeal acknowledgements, and submits case information to independent review organizations.
- Communicate effectively with appeal pharmacists regarding internal and external appeals.
- Make verbal outreach attempts to obtain necessary information for case review and record accurate information obtained on the call.
- Exhibit excellent phone and communication skills while providing complete and accurate information to members and providers.
- Performs all other related duties as assigned
Minimum Qualifications:
- 1 + years’ experience working as a certified pharmacy technician in a managed care or PBM setting required.
- Active, unrestricted certified pharmacist technician license required.
- Excellent organization details and strong detail orientation.
- Strong oral and written communication skills.
- Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities.
Preferred Qualifications:
- Experience working with commercial and medicare appeals preferred
Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
About Capital Rx
Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
Salary Range
$60,000 - $65,000 USD
This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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