Sr Appeal and Grievance Coordinator - MUST live in Louisiana

Aetna Medicaid Administrators

5d • $19 - $32

About The Position

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary MUST LIVE IN LOUISIANA Coordinate effective resolution of member or provider/practitioner appeals. Responsible for managing to resolution of appeals, complaints and grievances scenarios for all 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. May have contact with outside plan sponsors or regulators. -Research and resolve incoming electronic appeals, complaints and grievances as appropriate as a “single-point-of-contact” based on type of case. -Can identify and reroute inappropriate work items that do not meet appeal, complaint and grievance 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, appeals, complaints and grievances processes and procedures. -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 appeals, complaints and grievances 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 appeals, complaints and grievances, 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 ERT/SMRT/DOI/BBB appeals, complaints and grievances

Requirements

• Excellent written and oral communication skills.
• Ability to work cross organizationally.
• Strong analytical skills focusing on accuracy and attention to detail.

Nice To Haves

• Experience in reading or researching benefit language.
• Experience in research and analysis of claim processing a plus.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• Ability to maintain accuracy and production standards.

Responsibilities

• Coordinate effective resolution of member or provider/practitioner appeals.
• Responsible for managing to resolution of appeals, complaints and grievances scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units.
• Research and resolve incoming electronic appeals, complaints and grievances as appropriate as a “single-point-of-contact” based on type of case.
• Can identify and reroute inappropriate work items that do not meet appeal, complaint and grievance 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, appeals, complaints and grievances processes and procedures.
• 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 appeals, complaints and grievances 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 appeals, complaints and grievances, 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 ERT/SMRT/DOI/BBB appeals, complaints and grievances

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: Mid Level
• Education Level: Associate degree