Senior Coordinator – Complaint Appeals Operations

Job not on LinkedIn

3 days ago

🔔 Pennsylvania – Remote

Although this job is listed in Pennsylvania, this company may be open to hiring remote in other states.

💵 $18 - $35 / hour

⏰ Full Time

🟠 Senior

⚙️ Operations

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CVS Health

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Healthcare Insurance • Retail • Wellness

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

📋 Description

• Responsible for managing to resolution appeal scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units • Develop into a subject matter expert by providing training, coaching, or responding to complex issues • Research and resolves incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal • Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria • Identify trends in misrouted work • Assemble all data used in making denial determinations • 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 • Review clinical determinations and understand rationale for decisions • Research claim processing logic and systems to verify accuracy of claim payment, member eligibility data, etc. • Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, and similar situations requiring a higher level of expertise • Identifies trends and emerging issues and reports 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, Department of Insurance, Department of Health complaints on behalf of members or providers as assigned

🎯 Requirements

• Excellent verbal and written communication skills • Excellent customer service skills • Medicare knowledge and experience • 1-2 years Medicare part C Appeals experience (preferred) • Experience in reading or researching benefit language in SPDs or COCs (preferred) • Experience in research and analysis of claim processing (a plus) • Demonstrated ability to handle multiple assignments competently, accurately and efficiently • Experience documenting workflows and reengineering efforts (preferred) • Project management skills (preferred) • High School Diploma

🏖️ Benefits

• Affordable medical plan options • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching • Paid time off • Flexible work schedules • Family leave • Dependent care resources • Colleague assistance programs • Tuition assistance • Retiree medical access