[Remote] Coordinator, Complaint & Appeals Operations - prefer candidates in Virginia at CVS Health

Virginia, Minnesota, United States

Apply Now

Not SpecifiedCompensation

Entry Level & New GradExperience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Full time employment
Experience with appeals and grievances processes
Thorough knowledge of member and/or provider appeals, complaints and grievance policies
Strong analytical skills focusing on accuracy and attention to detail
Knowledge of clinical terminology, regulatory and accreditation requirements
Excellent verbal and written communication skills
Computer literacy

Responsibilities

Reviews and processes appeals and grievances filed by patients
Assists with adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues
Conducts reviews of decisions and case files to determine if there are errors in the application of law or evidence
Drafts and sends appeal decision letters
Identifies key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process
Documents patient billing questions and concerns
Prepares educational materials, training programs, or presentations to enhance understanding of the appeals and grievances process
Coaches junior colleagues on best practices and standard operating procedures
Assists with the training of junior-level staff to promote the development of departmental capabilities
Researches incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities
Researches Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial
Researches claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process
Identifies and researches all components within member or provider/practitioner appeals, complaints and grievance for all products and services
Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response
Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure
Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise
Identifies trends and emerging issues and reports on and gives input on potential solutions
Ability to meet demands of a high paced environment with tight turnaround times
Ability to make appropriate decisions based upon Aetna's current policies/guidelines
Collaborative working relationships

Skills

Compliance

Regulatory Requirements

Auditing

Data Analysis

Training

Communication

Problem-solving

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

Land your dream remote job 3x faster with AI

Try Jobo Free