Utilization Management Appeals Technician – Temp-to-Hire

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Capital Rx

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2017

⚕️ Healthcare Insurance

💳 Fintech

🤖 Artificial Intelligence

Healthcare Insurance • Fintech • Artificial Intelligence

Capital Rx is the fastest growing healthtech company in America, dedicated to transforming the prescription pricing and patient care landscape. Founded in 2017, it offers innovative pharmacy benefit management (PBM) services, including customizable pharmacy benefits for large employers and an AI-powered care navigation platform. Capital Rx focuses on delivering cost-effective solutions and operational efficiencies to clients while ensuring transparency and quality care for patients.

📋 Description

• 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. • 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

🎯 Requirements

• 1 + years’ experience working as a certified pharmacy technician in a managed care or PBM setting required. • Active, unrestricted PTCB or NHA Certified Pharmacy Technician certification 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. • Ability to work 12pm-9pm EST hours