Senior Coordinator, Complaint & Appeals - Work From Home

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Responsible for managing to resolution Fast Track Appeal scenarios for Medicare 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. Act as a subject matter expert by providing training, coaching, or responding to complex issues. May have contact with outside plan sponsors or regulators.

Research and resolves Fast Track Appeals as appropriate. Can identify and reroute inappropriate work items that do not meet 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. Follow up to assure Fast Track appeal is handled within established timeframe to meet company and regulatory requirements. Act as single point of contact for Fast Track appeals on behalf of members or providers, as assigned.

Knowledge of Fast Track Appeals and includes CMS Guidelines for Fast Track Appeals, MS Word, MS EXCEL, MHK, Quick Base applications, Avaya System, GPS

• Accurately review and process all Fast Track appeals within regulatory and internal time frames
• Ensure correct documentation and system entries for each case
• Verify all supporting materials and clinical information are complete and attached as required
• Communicate professionally and promptly with members, providers, and internal partners
• Double-check member language preferences (e.g., Blue Banner) and send communications in the appropriate language
• Adhere to workflow protocols for decision letters, effectuation, and case closure
• Identify and elevate errors, trends, or compliance risks to leadership promptly
• Maintain confidentiality and data security standards at all times
• Participate in quality audits and act on feedback for continuous improvement
• Collaborate with team members and support training or cross-coverage as needed

2-3 years' experience that includes both Medicare platforms, products, and benefits; patient management; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience. Experience in research and analysis of utilization management systems.

12-9 EST…