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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. Develop into 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 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.

Required Qualifications

• 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.

Preferred Qualifications

• Strong knowledge of all case types including all specialty case types

• Project management skills are preferred.

Education

High School Diploma

Pay Range

The typical pay range for this role is:

$18.50 - $42.35

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 11/30/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. 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.