Associate Manager, Complaint & Appeals - Work From Home

CVS Health•Work At Home-California, CA

2d•$46,988 - $112,200•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products, which may contain multiple issues and may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals. Identify trends and emerging issues and report and recommend solutions. Independently coaches’ others on complaints and appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, change, or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues. Responsible for serving as the main point of contact for plan leadership, compliance and State regulators as required. Medicare knowledge is a plus. Fast Turn Around of inventory, collaboration with clinical team and management. Attention to detail is needed and must be able to adapt to change due to up regulatory updates. A Brief Overview Will provide oversight to the Part C/Part B Preservice Expedited/Standard Appeal team. Through knowledge of the guidelines surrounding pre-service appeals is essential. Ability to provide focus on fast moving appeals is a must. Must have the ability to collaborate effectively with internal constituents to include Medical Directors, Nurses and different business partners who have an interest in appeals. Can troubleshoot problems and provide solutions to cases tasked to the team. Must be a great communicator when speaking to either the Medicare members or to the Appeals Team and Peers.

Requirements

Ability to interpret and understand Regulatory Guidance, Member Contract Materials and have oversight over inventory which has strict and short time constraints.
Fast paced environment
2+ years Leadership experience
Project Management
Colleague development

Nice To Haves

Previous Appeals or relatable experience
Medicare Knowledge is a plus

Responsibilities

Serves as a content model expert and mentor to team regarding CVS/Aetna's policies and procedures, regulatory and accreditation requirements.
Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints, and grievances handling.
Identifies trends and emerging issues and reports on and gives input on potential solutions.
Independently researches and translates policy and procedures into intelligent and logically written responses for ERT/SMRT/DOI/BBB and escalated cases.
Manages inventories to ensure state guidelines are met.
Educates analysts and business units of identified issues and potential risk. Initiates and encourages open and frequent communication between constituents.
Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.
Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.
Additional duties as assigned which will include a carrying a modified case load including but not limited to: Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints, and grievance criteria.
Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.
Ensure timely, customer focused response to appeals, complaints, and grievance.
Identify trends and emerging issues and report and recommend solutions.
Manage control and trend inventory, independently investigate, change, or revise policy to resolve the most escalated cases coming from broad internal and external constituents for all products and issues.
Responsible for serving as the main point of contact for plan leadership, compliance and State regulators as required.