Member Appeals Specialist

A company is looking for a Member Appeals Specialist (Remote).

Key Responsibilities

Triage and assign incoming member appeals and grievances; manage daily email and voicemail queues

Evaluate appeal eligibility, timeliness, and completeness of submitted documentation

Prepare and issue acknowledgment and decision letters using system templates

Required Qualifications

Prior experience managing member appeals (pharmacy or medical); knowledge of pre-service coverage preferred

Proficient in case management systems such as Jiva, and familiar with PBM tools (ESI), Facets, Outlook, and Teams

Strong organizational skills with proven reliability in remote work

Clear, professional communication and email etiquette; responsive and proactive follow-up

Team-oriented mindset with a commitment to learning, compliance, and quality improvement