Senior Coordinator, Complaints and Appeals

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Job Description
A Brief Overview
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.

What you will do

• 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.
  
  For this role you will need Minimum Requirements
• 5+ years work experience
• Adept at problem solving and decision making skills
  
  Education
• High school diploma or equivalent required.

• Requisition Job Description
  Requisition Job Description
  Position Summary
  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 i