Senior Coordinator, Complaint & Appeals

Job not on LinkedIn

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $18 - $31 / 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

• Oversee investigations and resolution of appeals scenarios for all products, including cases involving multiple issues and business units • 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 and independently investigate escalated cases • Serve as the point of contact for appeals inquiries from leadership, compliance, and state regulators • Maintain fast turnaround of inventory and collaborate with clinical teams and management • Escalate issues that may impact compliance timeliness • Serve as a content model expert and mentor regarding Aetna policies, procedures, regulatory, and accreditation requirements • Ensure team work meets federal and state requirements and quality measures for letter content and turnaround time • Research and translate policies and procedures into written responses for executive or senior leaders on escalated cases • Collaborate across functions, segments, and teams to create, populate, and trend reports • Identify potential risks and cost implications of inaccurate responses or decisions • Research incoming electronic appeals, complaints, and grievances; route inappropriate work items • Research plan designs or Evidence of Coverage to assess benefit or administrative denials • Research claim processing logic, eligibility, and billing/payment status • Identify and research all components of member or provider/practitioner appeals, complaints, and grievances

🎯 Requirements

• At least 2+ years in claim platforms, products and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit experience • High School or GED • Some Medicare and/or Medicaid knowledge • Experience reading or researching benefit language • Ability to work in a fast-paced, high-volume environment • Excellent verbal and written communication skills • Excellent organizational skills to handle high inventory and meet or exceed metrics • Solution-driven approach and ability to handle complex issues accurately

🏖️ Benefits

• 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