Medicaid Appeals & Grievance Associate Manager

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🔥 0 minutes ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

💵 $47k - $91.8k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👔 Manager

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

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.

📋 Description

• Coordinate effective resolution of member and/or provider/practitioner appeals, complaints, and grievances • Manage staff day to day to ensure effective and timely resolution across all products • Coordinate responses from multiple business units for complex issues • Implement Aetna's appeals, complaints, and grievances policies and procedures • Identify trends and issues; report on and recommend solutions • Meet financial, operational, and quality objectives of the unit • Manage team productivity, resources, workload, and customer satisfaction • Serve as a content model expert and mentor on policies, procedures, regulatory, and accreditation requirements • Manage performance measures and standards; coach team members • Participate in staff selection using education, experience, technical, and performance requirements • Build functional teams through training, assignments, coaching, and mentoring • Assess developmental needs and implement team and individual development plans • Ensure work meets federal and state requirements and quality measures for letter content and turnaround time • Hold individuals and teams accountable for results and recognize or reward performance • Lead change efforts and manage team transitions • Research and route incoming electronic appeals, complaints, and grievances • Research plan design or certification of coverage to assess benefit or administrative denials • Research claim processing logic, eligibility data, and billing/payment status • Identify and research all components of member or provider/practitioner appeals, complaints, and grievances • Carry a modified case load and perform additional assigned duties

🎯 Requirements

• Must live in Louisiana • Experience in reading or researching benefit language • Excellent verbal and written communication skills • Solid project management skills • Excellent customer service skills • Experience documenting workflows and reengineering efforts • Bachelor's degree or equivalent experience • Ability to work 40 hours per week • Preferred: 1–2 years of experience including claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit experience

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Comprehensive benefits package supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program eligibility