Job Description
Title: Grievance & Appeals, Sr. Coordinator
Location: Oklahoma
Job Type: Fully remote
Salary: 18.50 – 31.10 /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
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 coordinates effective resolution of member or provider/practitioner appeals. Responsible for managing to resolution of appeals, complaints and grievances 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. May have contact with outside plan sponsors or regulators.
- Research and resolve incoming electronic appeals, complaints and grievances as appropriate as a single-point-of-contact based on type of case.
- Can identify and reroute inappropriate work items that do not meet appeal, complaint and grievance 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, appeals, complaints and grievances processes and procedures.
- 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 appeals, complaints and grievances 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 appeals, complaints and grievances, 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 ERT/SMRT/DOI/BBB appeals, complaints and grievances
Required Qualifications
- Must reside in Oklahoma.
- 3+ years recent and relevant work experience.
- 2+ years experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
- Excellent written and oral communication skills.
- Ability to work cross organizationally.
- Strong analytical skills focusing on accuracy and attention to detail.
Preferred Qualifications
- Experience in reading or researching benefit language.
- Experience in research and analysis of claim processing a plus.
- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
- Ability to maintain accuracy and production standards.
- Ability to make appropriate decisions based upon Aetna’s current policies/guidelines.
- Knowledge of clinical terminology, regulatory and accreditation requirements.
- Negotiation skills.
Education
- Associate’s degree or equivalent work experience.