Job Description
Title: Grievance & Appeals Coordinator
Location: Oklahoma City OK US
time type: Full time
job requisition id: R0056142
Category: Plan Operations
Job Type: Fully remote
Salary: 17.00 – 25.15 /hour
Job Description:
Bring your heart to CVS Health. Every 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.
Position Summary
Position Summary:
Aetna Better Health of Oklahoma, a CVS Health company, is a trusted health partner in the local Oklahoma communities we serve. We provide a full array of innovative services that enhance overall wellness and improve everyday life for our members. At Aetna Better Health of Oklahoma, we value professional development and career growth. You will work along other colleagues who align on Heart at Work behaviors and bringing your heart to every moment of health. We will support you all the way!
This is a full-time teleworker opportunity in Oklahoma.
This position is responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and may require coordination of responses from 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 appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.
- Research Standard Plan Design or Certification of Coverage relevant 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 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.
- 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 in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
Required Qualifications
Required Qualifications:
- Must reside in Oklahoma.
- 1-2 year s experience that includes but is not limited to 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 reading or researching benefit language.
- 2+ years experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.).
Preferred Qualifications
Preferred Qualifications:
- Experience in research and analysis of claim processing a plus.
- Some college preferred.
Education
Education:
- High School or GED equivalent.