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.
Position Summary
Responsible for Oversight of processes related to resolution of grievance scenarios for all Medicare products, which may contain multiple issues and may require coordination of responses from multiple business units. Ensure timely, customer focused response to grievances. Identify trends and emerging issues. Daily tracking of reporting and proactively recommend solutions. Independently coaches others on complaints and appeals. Maintains compliance with CMS / Federal and/or State regulations. Manage control and trend inventory, independently investigate, change or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues. Responsible for serving as the main point of contact for plan leadership, compliance and State/Federal regulators as required. Medicare knowledge is required.
- Serves as a content model expert regarding Aetna's policies, procedures, and regulatory requirements.
- Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling.
- Proactively identifies trends and emerging issues and reports on and gives input on potential solutions.
- Independently researches and translates policy and procedures into intelligent and logically written responses for matrixed stakeholders and escalated cases.
- Manages inventories to ensure state and CMS guidelines are met.
- Oversees delivery of internal and external complaint KPIs.
- Educates supervisors and business units of identified issues and potential risk.
- Initiates and encourages open and frequent communication between constituents.
- Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.
- Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.
- Assignment of additional duties as assigned to leaders and frontline staff.
- Research/Track incoming electronic complaints and grievances to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet complaint and grievance criteria.
- Review Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
- Identify and research all components within member or provider/practitioner complaints and grievances for all products and services.
- 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 grievances.
- Independently coaches others on complaints and appeals ensuring compliance with Federal and/or State regulations.
- Manage control and trend inventory, independently investigate, change or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues.
- Review Online Monitoring Tracking (OMT) inventory, ensuring that leaders have a clear understanding of the process and rules.
- Collect and review data required for internal/external audits.
- Elevate trends that would negatively impact Star Rating. Perform analysis of the data to provide solutions.
- Manages team resources in accordance with approved budget.
- Oversees, approves, and denies overtime requests of internal staff, matrixed staff, and external staff/vendors in accordance with department policies and business needs.
- Closely monitors internal staff, matrixed staff, and external/vendor staffing productivity to meet department goals.
- Responsible for hiring, termination, and performance plan management for internal staff.
- Provides continuous coaching, direction, feedback and development for internal staff, matrixed staff and/or external vendors as required. Facilitates stretch opportunities to mentor and prepare staff for advancement.
Required Qualifications
- 3 to 5 years of Medicare experience
- 3 to 5 years of management experience
Preferred Qualifications
- Team leadership and team building skills.
- Analytical and planning skills.
- Relationship and change management skills.
- Organizational skills.
- Time management skills.
- Critical thinking skills.
Education
Bachelor’s Degree or 7 years of equivalent work experience
Pay Range
The typical pay range for this role is: $75,400.00 - $166,000.00. 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. This position also includes an award target in the company’s equity award program.
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 jobs.CVSHealth.com/benefits.
We anticipate the application window for this opening will close on: 03/15/2024.
CVS 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.
CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com. If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.
#J-18808-Ljbffr
