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CVS Health · 21 hours ago

Senior Coordinator, Complaints and Appeals

Harrisburg, PA

Full-time

Onsite

Senior Level

$18.50/hr - $35.29/hr

5+ years exp

CVS Health is the nation’s leading health solutions company, dedicated to transforming health care for millions of Americans. The Senior Coordinator, Complaints and Appeals will manage complex appeal scenarios, ensuring compliance and effective resolution while acting as a subject matter expert in the appeals process.

Health CareMedicalPharmaceuticalRetailSales

Responsibilities

Conducts team reviews, interpretations, and appeals filed by patients, escalating more complex issues and concerns to management for review and follow-up

Ensures adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures

Facilitates in-depth reviews of decisions and case files to determine if there are errors or anomalies in the application of law or evidence

Oversees the drafting and progression of appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution

Monitors key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process

Ensures all front-line associates promptly and accurately respond to all patient billing questions and concerns

Facilitates and provides educational materials, training programs, and presentations to enhance understanding of the appeals and grievances process

Coaches and mentors other colleagues in techniques, processes, and responsibilities for effectively handling member complaints and appeals

Trains junior-level staff to promote the development of departmental capabilities

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

Qualification

ResearchAnalysisProblem solvingDecision makingCustomer serviceLeadershipComputer navigationMultitaskingWorkflow documentationCommunication skillsProject management

Required

5+ years work experience

Adept at problem solving and decision making skills

1 years experience in reading or researching benefit language in SPDs or COCs

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

High school diploma or equivalent required

Preferred

1 years of experience in research and analysis of claim processing

1-2 years Medicare part C Appeals experience

Project management skills are preferred

Strong knowledge of all case types including all specialty case types

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.