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CVS Health · 18 hours ago

Senior Coordinator - Complaint & Appeals

Sacramento, CA

Full-time

Onsite

Mid, Senior Level

$18.50/hr - $38.82/hr

2+ years exp

CVS Health is the nation’s leading health solutions company, dedicated to transforming health care. The Senior Coordinator for Complaint & Appeals is responsible for overseeing the investigation and resolution of appeals, ensuring compliance with regulations, and managing case loads while providing customer-focused responses.

Health CareMedicalPharmaceuticalRetailSales

Responsibilities

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 a 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

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

Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services

Qualification

Medicare experienceCompliance knowledgeRegulatory analysisElectronic Health RecordsExcel proficiencyBilingualSolution drivenVerbal communicationWritten communicationOrganizational skills

Required

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

2+ years of Medicare Experience

Medicare and/or Medicaid knowledge

Experience in reading or researching benefit language

Ability to work in fast paced, high volume environment

Proficient in computer use, including Excel and Electronic Health Records (EHR) systems

High School Diploma or GED

Preferred

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

Bilingual is a plus

Benefits

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.