Senior Coordinator, Complaint & Appeals

Job not on LinkedIn

🔥 28 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $18 - $38 / hour

⏰ Full Time

🟠 Senior

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

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.

📋 Description

• Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products • Ensure timely, customer focused response to appeals • Independently coaches others on appeals ensuring compliance with Federal and/or State regulations • Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases • Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit • Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria • Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial • Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process

🎯 Requirements

• At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience • Some Medicare and/or Medicaid knowledge • Experience in reading or researching benefit language • Ability to work in fast paced, high volume 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

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs