Cdr, Complaint & Appeals

Job Description

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

Required hours: Wednesday-Sunday with a flexible start time between 9am-1pm.

• 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.

Additional duties as assigned which will include a 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, complaints and grievance for all products and services.

Required Qualifications
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

Preferred Qualifications

• Some Medicare and/or Medicaid knowledge
• Experience in reading or researching benefit language
• Ability to work in fast paced, high volume environment
• 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

Education High School or GED

Pay Range

The typical pay range for this role is: $17.00 – $29.30.

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

CVS Health requires certain colleagues 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, religious belief, or other legally recognized reasons that prevents them from being 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 or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.