-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

-Experience in reading or researching benefit language.
-1-2 years experience that includes but is not limited too claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.

Preferred Qualifications
-Experience in research and analysis of claim processing a plus.

Education

-Some college preferred.
-High School or GED equivalent.

Pay Range

The typical pay range for this role is:

$17.00 - $25.65

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.

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 Benefits | CVS Health

We anticipate the application window for this opening will close on: 11/30/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.