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Job DescriptionResponsible for investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses form multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions.Research incoming electronic complaints/appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet complaint/appeal criteria.-Research Plan Sponsor claim fiduciary responsibility, assemble data used in making the denial determination, assemble, summarize and send to Plan Sponsor contact.-Research Standard Plan Design or Certification of Coverage pertinent to the member to determine accuracy/appropriateness of benefit/administrative denial.-Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.-Identify and research all components within member or provider/practitioner complaints/appeals for all products and services.-Triage incomplete components of complaints/appeals 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 complaints/appeals including final communication to member/provider for final resolution and closure.-Serve as a technical resource to colleagues on claim 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. Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements.-Act as single point of contact for the Executive complaints and appeals and Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers, as assigned.-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.-Thorough knowledge of member and provider appeal 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 in order to navigate through internal/external computer systems, including Excel and Microsoft Word.Required QualificationsCertified CoderExperience in reading or researching benefit language in SPDs or COCs.1-2 years experience that includes both HMO and Traditional claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.Experience in research and analysis of claim processing a plus.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred QualificationsCertified Coder, Experience in research and analysis of claim processing a plus.EducationCertified Coder.Some college preferred.HIgh School or GED equivalent.Business OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
Vacancy expired!