Senior Coordinator, Complaint Appeals Operations

March 24

🌽 Illinois – Remote

Although this job is listed in Illinois, this company may be open to hiring remote in other states.

🌲 Oregon – Remote

Although this job is listed in Oregon, this company may be open to hiring remote in other states.

+2 more states

🌽 Illinois – Remote 🌲 Oregon – Remote 🤠 Texas – Remote ☕ Washington – Remote

💵 $18 - $35 / hour

⏰ Full Time

🟠 Senior

⚙️ Operations

Apply Now

Receive Emails with Similar Jobs

CVS Health

WebsiteLinkedInAll Job Openings

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.

Retail • Pharmacy Benefits Management • Health Insurance • Health Care • Pharmacy

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

📋 Description

• Responsible for managing to resolution appeal 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. • Act as a subject matter expert by providing training, coaching, or responding to complex issues. • May have contact with outside plan sponsors or regulators. • Research and resolves incoming electronic appeals as appropriate as a "single-point-of-contact" based on type of appeal. • Can identify and reroute inappropriate work items that do not meet complaint/appeal 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, fiduciary responsibility and appeals processes and procedures. • Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial. • 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 complaints/appeals 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 complaint/appeal issues, 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 Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned.

🎯 Requirements

• 1-2 years Medicare part C Appeals experience. • 1 years experience in reading or researching benefit language in SPDs or COCs. • 1 years of experience in research and analysis of claim processing. • Demonstrated ability to handle multiple assignments competently, accurately and efficiently. • Excellent verbal and written communication skills. • Computer navigation ability and ability to multitask. • Excellent customer service skills. • Strong Leadership skills • Experience documenting workflows and reengineering efforts.

🏖️ Benefits

• Affordable medical plan options • A 401(k) plan (including matching company contributions) • 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.