Senior Coordinator Complaint Appeals Operations - Work At Home at CVS Health

Florida City, Florida, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

1-2 years Medicare Part C Appeals experience
Experience in reading or researching benefit language in SPDs or COCs
Experience in research and analysis of claim processing (a plus)
Demonstrated ability to handle multiple assignments competently, accurately and efficiently
Excellent verbal and written communication skills
Excellent customer service skills
Experience documenting workflows and reengineering efforts
High School Diploma

Responsibilities

Manage 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
Develop into a subject matter expert by providing training, coaching, or responding to complex issues
May have contact with outside plan sponsors or regulators
Research and resolve incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal
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 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
Review a clinical determination and understand rationale for decision
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
Coordinate 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
Identify trends and emerging issues and report on and give input on potential solutions
Deliver internal quality reviews, provide appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required
Understand and 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

Skills

Key technologies and capabilities for this role

appeals processingcomplaint resolutionhealthcare operationsclaim processingplan design researchclinical determination reviewworkflow managementcross-department coordinationfiduciary responsibilityregulatory compliancedata assemblytrend identification

Questions & Answers

Common questions about this position

Is this position remote or work-from-home?

Yes, this is a Work At Home position.

What are the required qualifications for this role?

Required qualifications include 1-2 years Medicare part C Appeals experience, experience in reading or researching benefit language in SPDs or COCs, experience in research and analysis of claim processing as a plus, demonstrated ability to handle multiple assignments competently, accurately and efficiently, and excellent verbal and written communication skills.

What is the salary range for this position?

This information is not specified in the job description.

What benefits does CVS Health offer?

This information is not specified in the job description.

What makes a strong candidate for this Senior Coordinator role?

A strong candidate will have 1-2 years of Medicare part C Appeals experience, skills in researching benefit language in SPDs or COCs, ability to handle multiple assignments efficiently, and excellent communication skills, along with experience in claim processing analysis.

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.

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