Complaint Appeals, Senior Coordinator - Fully Remote

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

This position is available nationwide, as it is a fully remote position.

Position Summary

Provide support to the Supervisors by coaching, mentoring, and training new staff. Oversight over inventory.

• Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer-focused response to appeals.
• Identify trends and emerging issues and report and recommend solutions. 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 coming from internal and external constituents for all products.
• Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance, and State regulators. Understand and adapt to departmental process and policies.
• Medicare knowledge is a plus. Fast Turn Around of inventory, collaboration with clinical team and management. Attention to detail is needed and must be able to maintain compliance turn-around times, with accurate case resolution or research.
• Remain a part of the solution by escalating issues that may impact compliance timeliness.
• Additional duties as assigned which will include carrying a modified case load including but not limited to:
• Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements.
• Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints, and grievances handling.
• Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases.
• Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.
• Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.
• Additional duties as assigned which will include carrying a modified case load including but not limited to:
• Research incoming electronic appeals, complaints, and grievance to identify if appropriate for unit based upon published business responsibilities. 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 (Evidence 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.
• Research incoming electronic appeals, complaints, and grievance to identify if appropriate for unit based upon published business responsibilities. 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.
• Identify and research all components within member or provider/practitioner appeals.