Coordinator, Grievance and Appeals-Remote

Putting People First in Pharmacy- Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.

The Navitus Grievance and Appeals process is an essential function to Navitus’ compliance with CMS regulations, accrediting body standards, other applicable regulatory requirements, and member expectations. The Navitus Grievance and Appeals department serves as the central repository for all complaints received by Navitus and all appeal requests where the responsibility has been delegated to Navitus. The Navitus Grievance & Appeals Coordinator serves to administrate the Navitus Grievance and Appeals processes as outlined by Client/Plan Sponsors, departmental policies and procedures, and regulatory standards. Coordinator, Grievance and Appeals serves as a liaison for Navitus members, prescribers and pharmacies regarding complaints or appeals related to denied pharmacy claims, membership and benefit issues, reimbursements and quality of care or service. Coordinator, Grievance and Appeals is responsible for presentation of the member appeals as required to the Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, Client, and/or the contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies, and standards.

Is this you? Find out more below!

How do I make an impact on my team?

• Administrate Standard and Expedited Appeals Processes as outlined in Client/Plan Sponsor Member Handbook and in compliance with applicable accrediting body standards, CMS and other state or federal regulatory requirements. Strict adherence to turn-around time and quality of documentation standards established in accordance with regulatory standards is required.
• Act as the primary investigator and contact person for member, prescriber or pharmacy grievances and appeals, which includes sending the appropriate acknowledgement of the grievance/appeal per policy, educating the member and/or member representative about the grievance/appeal, gathering all pertinent and relevant information regarding the grievance/appeal, notifying the appropriate parties of the resolution per policy and ensuring that all internal processes are completed to resolve the issue.
• Learn and understand the up and downstream processes related to grievances and appeals.
• Contribute to the management of grievance and appeal resources/materials.
• Gather and provide documentation and research outcomes within required timeframes to Clients/Plan Sponsors who manage their own appeals.
• Ensure all decisions for approval are effectuated correctly.
• Thoroughly document all action taken on behalf of the member to resolve the grievance/appeal.
• Participate in audits, including document preparation and participation in on-site or remote audits, as a subject matter expert.
• Abiding by HIPAA regulations and confidentiality requirements; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or other department staff.
• Work with appropriate staff to resolve member and provider complaints; formulate improvement measures and responses; prepare written correspondence to member and others as required.

What our team expects from you?

• High School Diploma or equivalent required. 2 years post high school education or bachelor’s degree preferred. CPhT certification or ability to obtain desired and preferred
• 2-3 years of managed care and/or insurance background in addition to a strong knowledge of CMS coverage determination and redetermination processes preferred.
• Experience with CMS and/or NCQA audits strongly desired.
• Proven success in documenting case files and managing multiple cases within requires timeframes desired.
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Hours/Location: Monday-Friday 8:00am-5:00pm CST, Remote
• Paid Volunteer Hours
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!
• Top of the industry benefits for Health, Dental, and Vision insurance, Flexible Spending Account, Paid Time Off, Eight paid holidays, 401K, Short-term and Long-term disability, College Savings Plan, Paid Parental Leave, Adoption Assistance Program, and Employee Assistance Program