Appeals Technician

Responsible for taking incoming requests for first, second level and external appeals while ensuring high level of customer service and maximizing productivity. Working 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. Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements. Remaining current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities. Following all internal Standard Operating Procedures and adhering to HIPAA guidelines and policies. Reviewing all cases received, to verify if case meets qualifications for appeal review. Performing triple check to ensure quality reviews and handling in accordance with policies and procedures. Updating case types, sending appeal acknowledgements, and submitting case information to independent review organizations. Communicating effectively with appeal pharmacists regarding internal and external appeals. Making verbal outreach attempts to obtain necessary information for case review and record accurate information obtained on the call. Exhibiting excellent phone and communication skills while providing complete and accurate information to members and providers. Performing all other related duties as assigned