Senior Coordinator, Complaint & Appeals - Remote

CVS Health

3d•Remote

About The Position

Responsible for managing to resolution Fast Track Appeal scenarios for Medicare products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. Act as a subject matter expert by providing training, coaching, or responding to complex issues. May have contact with outside plan sponsors or regulators. Research and resolves Fast Track Appeals as appropriate. Can identify and reroute inappropriate work items that do not meet appeal criteria as well as identify trends in misrouted work. Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures. Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial. Can review a clinical determination and understand rationale for decision. Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process. Serves as point person for newer staff in answering questions associated with claims/customer service systems and products. Educates team mates as well as other areas on all components within member or provider/practitioner complaints/appeals for all products and services. Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise. Identifies trends and emerging issues and reports on and gives input on potential solutions. Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required. Understands and can respond to Executive complaints and appeals. Follow up to assure Fast Track appeal is handled within established timeframe to meet company and regulatory requirements. Act as single point of contact for Fast Track appeals on behalf of members or providers, as assigned.

Requirements

Knowledge of Fast Track Appeals and CMS Guidelines for Fast Track Appeals
MS Word
MS EXCEL
MHK
QuickBase applications
Avaya System
GPS
HS Diploma, Associate's degree or equivalent experience

Nice To Haves

2-3 years' experience that includes both Medicare platforms, products, and benefits
Patient management experience
Compliance and regulatory analysis experience
Special investigations experience
Provider relations experience
Customer service or audit experience
Experience in research and analysis of utilization management systems

Responsibilities

Manage to resolution Fast Track Appeal scenarios for Medicare products.
Coordinate responses from multiple business units for complex appeals.
Act as a subject matter expert, providing training, coaching, and responding to complex issues.
Research and resolve Fast Track Appeals.
Identify and reroute inappropriate work items that do not meet appeal criteria.
Identify trends in misrouted work.
Assemble data for denial determinations.
Act as a subject matter expert regarding unit workflows, fiduciary responsibility, and appeals processes.
Research standard plan design, certification of coverage, and potential contractual deviations.
Review clinical determinations and understand rationale for decisions.
Research claim processing logic and systems to verify accuracy of claim payment, member eligibility, billing/payment status.
Serve as a point person for newer staff, answering questions about claims/customer service systems and products.
Educate teammates and other areas on complaint/appeal components for all products and services.
Coordinate efforts internally and across departments to resolve claims research, SPD/COC interpretation, letter content, regulatory language, and triaging of issues.
Identify trends and emerging issues, reporting on them and providing input on potential solutions.
Deliver internal quality reviews.
Provide support in third-party audits, customer meetings, regulatory meetings, and consultant meetings.
Respond to Executive complaints and appeals.
Follow up to ensure Fast Track appeals are handled within established timeframes.
Act as a single point of contact for Fast Track appeals on behalf of members or providers.