Member Appeals Specialist in Boston, Massachusetts - #72527 | VanderHouwen

Description

Job Id: 72527

Member Appeals Specialist
Our client is seeking a detail-oriented Member Appeals Specialist to support the review and resolution of member pharmacy coverage appeals within a highly regulated healthcare environment. This individual will manage appeals from intake through final determination, ensuring compliance with established timelines, regulatory requirements, and internal quality standards. The ideal candidate is organized, analytical, customer-focused, and thrives in a collaborative remote setting.

This role is fully remote.

Member Appeals Specialist Responsibilities

• Manage assigned member appeals from initial intake through final resolution, ensuring compliance with regulatory and internal turnaround requirements.
• Review appeal submissions to validate eligibility, timeliness, completeness, and supporting documentation requirements.
• Prepare and distribute acknowledgment and determination correspondence utilizing established templates, reference materials, and compliance guidelines.
• Conduct outreach to members, representatives, providers, or other stakeholders to obtain additional information and supporting documentation when needed.
• Collaborate with cross-functional teams, including clinical, pharmacy, quality, and leadership stakeholders, to facilitate timely case progression and resolution.
• Maintain accurate case documentation and updates within designated case management and healthcare systems.
• Manage a high-volume caseload while consistently meeting productivity, accuracy, and service expectations.
• Utilize multiple systems and communication platforms to process appeals, research information, and coordinate case-related activities.

Member Appeals Specialist Qualifications

• Experience handling member appeals within a healthcare, health plan, managed care, or insurance environment.
• Demonstrated ability to independently manage cases through a structured case management system from initiation to completion.
• Strong understanding of regulatory timelines, documentation requirements, and compliance-focused workflows.
• Excellent written and verbal communication skills, including professional email correspondence and documentation preparation.
• Highly organized with exceptional attention to detail and the ability to manage multiple priorities simultaneously.
• Comfortable learning and applying policies, procedures, reference materials, and regulatory guidelines to support consistent decision-making.
• Proficient with Microsoft Outlook, virtual collaboration tools, and healthcare-related systems.
• Ability to work effectively in a fully remote team environment while proactively seeking guidance and collaborating with colleagues as needed.

Compensation: $20-$22/hr. (DOE)

VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

Meet VanderHouwen
What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we’re in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies’ staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.

VanderHouwen is an award-winning, Women & Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!

VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.

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