Vacancy expired!
Job DescriptionCoordinate effective resolution of member or provider/practitioner appeals.Responsible for managing to resolution of appeals, complaints and grievances scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. May have contact with outside plan sponsors or regulators.-Research and resolve incoming electronic appeals, complaints and grievances as appropriate as a “single-point-of-contact” based on type of case. -Can identify and reroute inappropriate work items that do not meet appeal, complaint and grievance criteria as well as identify trends in misrouted work.-Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, appeals, complaints and grievances processes and procedures.-Can review a clinical determination and understand rationale for decision.-Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process. -Serves as point person for newer staff in answering questions associated with claims/customer service systems and products.-Educates team mates as well as other areas on all components within member or provider/practitioner appeals, complaints and grievances for all products and services.-Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of appeals, complaints and grievances, and similar situations requiring a higher level of expertise.-Identifies trends and emerging issues and reports on and gives input on potential solutions.-Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required.-Understands and can respond to ERT/SMRT/DOI/BBB appeals, complaints and grievancesRequired QualificationsExcellent written and oral communication skills.Ability to work cross organizationally.Strong analytical skills focusing on accuracy and attention to detail.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.
Preferred QualificationsExperience in reading or researching benefit language.Experience in research and analysis of claim processing a plus.Demonstrated ability to handle multiple assignments competently, accurately and efficiently.Ability to maintain accuracy and production standards.EducationAssociate's degree or equivalent work experience.Business OverviewAt Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
Full-time- ID: #23474646
- State: Kansas Workfromhome 00000 Workfromhome USA
- City: Workfromhome
- Salary: USD TBD TBD
- Showed: 2021-11-25
- Deadline: 2022-01-24
- Category: Et cetera