Complaint Appeals, Senior Coordinator - Fully Remote

CVS Health•Work At Home-Pennsylvania, NV

3d•$19 - $39•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. This position is available nationwide, as it is a fully remote position. Position Summary Provide support to the Supervisors by coaching, mentoring and training new staff. Oversight over inventory. • 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 appeals ensuring compliance with Federal and/or State regulations. • Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases coming from internal and external constituents for all products. • Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance and State regulators. Understand and adapt to departmental process and policies. • 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 maintain compliance turn-around times, with accurate case resolution or research. • Remain a part of the solution by escalating issues that may impact compliance timeliness. -Additional duties as assigned which will include a carrying a modified case load including but not limited to • Serves as a content model expert and mentor to team regarding 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. • Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases. • 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 (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. • Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process. • 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.

Requirements

2-4 years of experience in a Customer Service role.
2-4 years of Medicare and/or Medicaid knowledge.
At least 2-4 years of experience that includes clinical and claim platforms, benefits and services.
Compliance and regulatory knowledge.
Provider relations and customer service experience.
Experience in reading or researching benefit language.
Ability to work in a fast-paced environment.
Excellent verbal and written communication skills.
Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics.
Solution-driven and can handle complex issues with accuracy.
Availability to work alternating weekends for oversight of analysts on alternate schedule.
High School Diploma or GED required or 2-4 years of equivalent work experience.

Nice To Haves

Audit experience
Critical thinking experience.
Ability to work complex issues
Team Player
Exhibit How We Work Behaviors
Solution Driven
Medicare knowledge is a plus.

Responsibilities

Oversight of investigation and resolution of appeals scenarios for all products, which may contain multiple issues and require coordination of responses from multiple business units.
Ensure timely, customer-focused response to appeals.
Identify trends and emerging issues, report and recommend solutions.
Independently coach others on appeals, ensuring compliance with Federal and/or State regulations.
Manage control and trend inventory, independently investigate, adapt to changes or revise policy to resolve escalated cases.
Serve as the point of contact for appeals inquiries from leadership, compliance, and State regulators.
Understand and adapt to departmental processes and policies.
Collaborate with clinical team and management for fast turnaround of inventory.
Maintain compliance turn-around times with accurate case resolution or research.
Escalate issues that may impact compliance timeliness.
Serve as a content model expert and mentor to the team regarding Aetna's policies and procedures, regulatory and accreditation requirements.
Ensure the work of the team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints, and grievances handling.
Independently research and translate policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases.
Work 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.
Research incoming electronic appeals, complaints, and grievances to identify if appropriate for the unit.
Identify the correct resource and reroute inappropriate work items.
Research Standard Plan Design or Certification of Coverage (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of the appeal process.
Identify and research all components within member or provider/practitioner appeals.