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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
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 complaints and appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, change, or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues. Responsible for serving as the main point of contact for plan leadership, compliance and State regulators as required. 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 adapt to change due to up regulatory updates.
This Supervisor will provide oversight to the Part C/Part B Preservice Expedited/Standard Appeal team. Through knowledge of the guidelines surrounding pre-service appeals is essential. Ability to provide focus on fast moving appeals is a must. Must have the ability to collaborate effectively with internal constituents to include Medical Directors, Nurses and different business partners who have an interest in appeals. Can troubleshoot problems and provide solutions to cases tasked to the team. Must be a great communicator when speaking to either the Medicare members or to the Appeals Team and Peers.
-Serves as a content model expert and mentor to team regarding CVS/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.
-Identifies trends and emerging issues and reports on and gives input on potential solutions.
-Independently researches and translates policy and procedures into intelligent and logically written responses for ERT/SMRT/DOI/BBB and escalated cases.
-Manages inventories to ensure state guidelines are met.
-Educates analysts and business units of identified issues and potential risk. Initiates and encourages open and frequent communication between constituents.
-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 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.
-Ensure timely, customer focused response to appeals, complaints, and grievance.
-Identify trends and emerging issues and report and recommend solutions.
-Manage control and trend inventory, independently investigate, change, or revise policy to resolve the most escalated cases coming from broad internal and external constituents for all products and issues. -Responsible for serving as the main point of contact for plan leadership, compliance and State regulators as required.
Required Qualifications
-Medicare Knowledge is a plus
-Ability to interpret and understand Regulatory Guidance, Member Contract Materials and have oversight over inventory which has strict and short time constraints.
– Fast paced environment
– 2+ years Leadership experience
– Project Management
– Colleague development
Preferred Qualifications
-Previous Appeals or relatable experience
Education
-Bachelor’s Degree or equivalent work experience
Pay Range
The typical pay range for this role is:
$40,600.00 – $89,300.00
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
We anticipate the application window for this opening will close on: 08/02/2024
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.