Company Overview:

Join us in our mission to transform healthcare! nirvanaHealth (under RxAdvance Corp.) is committed to bringing the art of the possible to the payer and PBM industries. We invest in our employees at every stage of life. Success radiates across all levels of our organization, driven by competitive benefits and a strong focus on employee wellness, we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria – the first robotic process automation cloud platform designed for healthcare.

Under the leadership of our Chairman John Sculley, former Apple CEO, and our President & CEO Ravi Ika, nirvanaHealth endeavors to sizably reduce the $1 trillion in waste in healthcare administrative and medical costs. We are seeking self-determined players to join our team – folks who embrace the grind and hustle of a growing company, are collaborative and innovative, are life-long learners and growers, and have an entrepreneurial and positive mindset.

Job Summary:

The Appeals & Grievances Coordinator organizes and assists daily operations within the organization. These operations are primarily focused on appeals and grievances, utilization management, and communications. They work closely with stakeholders to manage daily operations, scope, and quality to meet established service level agreements.

Job Responsibilities (but not limited to):

• Receives inbound calls, faxes, emails, and mail to initiate an appeal or grievance.
• Makes outbound calls to obtain additional information pertaining to an appeal or grievance.
• Collects, organizes, and tracks information received from a variety of resources to facilitate and expedite the processing of requests
• Generates applicable letters for members and providers in accordance with accreditation and regulatory standards.
• Assists with business operations in the development of communications (e.g., letters, forms) and configuration within the platforms in compliance with state and federal requirements.
• Assists with compiling statistical data, reporting, and analyses to demonstrate clinical, financial, and operational effectiveness and quality.
• Provides support for internal and external audits and surveys.

Education and/or Training:

• High School degree or equivalent is required.
• Bachelor’s degree in public policy or a healthcare related field is preferred; equivalent work experience in related field is acceptable.
• A minimum of 2 years’ relevant experience within a Medicare or Medicare Advantage setting is required.
• Prior knowledge of CMS guidance/regulations is required.
• Experience with appeals and grievances and/or prior authorization processes is preferred.