Senior Coordinator, Complaint Appeals

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🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $18 - $35 / 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 managing to resolution appeal scenarios for all products • Develop into a subject matter expert by providing training, coaching, or responding to complex issues • Research and resolves incoming electronic appeals as appropriate • Can identify and reroute inappropriate work items • Assemble all data used in making denial determinations • Research standard plan design, certification of coverage and potential contractual deviations • Can review a clinical determination and understand rationale for decision • Able to research claim processing logic and various systems • Coordinates efforts both internally and across departments • Identifies trends and emerging issues and reports on potential solutions • Delivers internal quality reviews and provides appropriate support in audits and meetings • Understands and can respond to Executive complaints and appeals as assigned

🎯 Requirements

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

🏖️ Benefits

• Medical, dental, and vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources, based on eligibility