Senior Coordinator, Complaint & Appeals - Remote

CVS Health

7d • $19 - $32 • 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. A Brief Overview This position is for a Dental Senior. Prepares information and reports needed to address matters regarding complaints, appeals, and grievances. Carries out policies, procedures, and programs to ensure compliance with federal and/or state regulations. Schedule: Wednesday-Sunday

Requirements

• Minimum Requirements - Preferred 3-5 years of experience in a Customer Service role.
• At least 5 years of experience that includes but is not limited to claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
• Ability to work in 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 equivalent required.

Nice To Haves

• Experience in reading or researching benefit language
• Medicare and/or Medicaid knowledge

Responsibilities

• Conducts team reviews, interpretations, and appeals filed by patients, escalating more complex issues and concerns to management for review and follow-up.
• Ensures adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
• Facilitates in-depth reviews of decisions and case files to determine if there are errors or anomalies in the application of law or evidence.
• Oversees the drafting and progression of appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution.
• Monitors key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process.
• Ensures all front-line associates promptly and accurately respond to all patient billing questions and concerns.
• Facilitates and provides educational materials, training programs, and presentations to enhance understanding of the appeals and grievances process.
• Coaches and mentors other colleagues in techniques, processes, and responsibilities for effectively handling member complaints and appeals.
• Trains junior-level staff to promote the development of departmental capabilities.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees