Senior Appeal and Grievance Analyst OhioRISE
CVS Pharmacy - Columbus, OH
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Job DescriptionBusiness OverviewAs part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.Position Summary:This is a full time teleworker position in Ohio. 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.Fundamental Components:- 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- Ability to make appropriate decisions based upon Aetna's current policies/guidelines.Required 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.- Excellent written and oral communication skills.- Ability to work cross organizationally.- Strong analytical skills focusing on accuracy and attention to detail.- Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word- Knowledge of clinical terminology, regulatory and accreditation requirements.- Ohio residency; must reside within proximity/commutable distance to the New Albany office address.- Ability to travel to the office as required. Must possess reliable transportation, valid and active driver's license, and proof of vehicle insurance.COVID RequirementsCOVID-19 Vaccination RequirementCVS 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.Preferred Qualifications- Associate's degree is preferred.- Negotiation skills are preferred.Education- Associate's degree or equivalent work experience.Business OverviewBring your heart to CVS HealthEvery 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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. 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.
Created: 2024-09-07