Senior Coordinator, Complaint & Appeals - Remote

CVS Health

2d•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 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.

Requirements

At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
High School or GED

Nice To Haves

Some Medicare and/or Medicaid knowledge
Experience in reading or researching benefit language
Ability to work in fast paced, high volume 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

Responsibilities

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.
Serve 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.
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.
Carry a modified case load.
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.
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.
Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.