Investigates and resolution of dental appeals, which may contain multiple issues and, may require coordination of responses from business units.

Ensure timely, customer focused response to dental appeals.

Identify trends and emerging issues and report and recommend solutions.

Independently coaches others on appeals ensuring compliance with Federal and/or State regulations.

Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases coming from internal and external constituents for all products.

Responsible for serving as the point of contact for the dental appeal if there is an inquiry from leadership, compliance and State regulators.

Understand and adapt to departmental process and policies.

Medicare knowledge is a plus.

Fast Turn Around of inventory, collaboration with clinical team and management.

Attention to detail is needed and must be able to maintain compliance turn-around times, with accurate case resolution or research.

Remain a part of the solution by escalating issues that may impact compliance timeliness. Additional duties as assigned which will include a carrying a modified case load including but not limited to:

-Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation 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.

-Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases.

-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.

-Additional duties as assigned which will include a carrying a modified case load including but not limited to:-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 (Evidence 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.

--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.

-Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.

Required Qualifications

- Preferred 3-5 years of experience in a Customer Service

role.

- Experience in reading or researching benefit language

- Medicare and/or Medicaid knowledge

- At least 5 years of experience that includes but is not

limited to claim platforms, products, and benefits;

patient management; product or contract drafting;

compliance and regulatory analysis; special

investigations; provider relations; customer service or

audit experience

- Ability to work in fast paced environment

- Excellent verbal and written communication skills.

- Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics.

- Solution driven and can handle complex issues with accuracy.

- Availability to work alternating weekends for oversight of analysts on alternate schedule.

Preferred Qualifications

The position is posted for the Pittsburgh office; however, this position is available nationwide, as it is a fully remote position. Internal candidates

Ability to work complex issues

Team Player

Exhibit How We Work Behaviors

Solution Driven

Education

Bachelor's Degree or equivalent work experience

Pay Range

The typical pay range for this role is:

$18.50 - $38.82

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.