Senior Coordinator, Complaint Appeals

Job not on LinkedIn

🔥 16 hours ago

🏈 Alabama, Arizona, +17 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🎰 Nevada – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🤠 Texas – Remote 🍁 Vermont – Remote ☕ Washington – Remote

💵 $18 - $38 / hour

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Provide support to Supervisors by coaching, mentoring and training new staff • Oversee inventory • Investigate and resolve appeals scenarios for all products, coordinating responses from multiple business units when needed • Ensure timely, customer-focused responses to appeals • Identify trends and emerging issues, report findings, and recommend solutions • Coach others on appeals while ensuring compliance with federal and state regulations • Manage, control, and trend inventory • Independently investigate and resolve the most escalated cases from internal and external constituents • Serve as point of contact for appeals inquiries from leadership, compliance, and state regulators • Collaborate with clinical teams and management to maintain accurate case resolution and compliance turnaround times • Escalate issues that may impact compliance timeliness • Serve as a content model expert and mentor regarding Aetna policies and procedures and regulatory/accreditation requirements • Ensure team work meets federal and state requirements and quality measures for letter content and turnaround times • Research and translate policies and procedures into written responses for Executive or Senior leaders on escalated cases • Work across functions, segments, and teams to create, populate, and trend reports for escalated-case resolution • Identify potential risks and cost implications • Research incoming electronic appeals, complaints, and grievances; determine routing and reroute inappropriate work items • Research plan designs or Evidence of Coverage to assess benefit or administrative denials • Research claim-processing logic, member eligibility, and billing/payment status • Identify and research all components within member or provider/practitioner appeals

🎯 Requirements

• 2-4 years of experience in a Customer Service role • 2-4 years of Medicare and/or Medicaid knowledge • At least 2-4 years of experience including clinical and claim platforms, benefits and services, compliance and regulatory knowledge, provider relations and customer service • Experience in reading or researching benefit language • Ability to work in a fast paced environment • Excellent verbal and written communication skills • Excellent organizational skills to handle high inventory and meet or exceed metrics • Solution driven and able to handle complex issues with accuracy • Availability to work alternating weekends for oversight of analysts on alternate schedule • High School Diploma or GED required, or 2-4 years of equivalent work experience • Audit experience • Critical thinking experience • Ability to work complex issues • Team player • Exhibit How We Work Behaviors • Solution Driven

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility