Complaint & Appeal Program Manager

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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.

Position Summary
Establish and maintain in collaboration with all segments and business units, consistent policies and procedures defining the administration and resolution of complaints grievances and appeals from Aetna member and providers compliant with legislative, regulatory and accreditation requirements. Maintain this infrastructure to assure ease of use and consistent resolution responses are accessible to all operational resolution teams and business units and subject matter experts. The Quality department offers a supportive team environment, and Management provides support but autonomy is encouraged. This is a full-time position. This role offers some flexibility in day-to-day scheduling but meeting the needs of growing business is always priority.

• Manages team's productivity and resources, communicates productivity expectations, and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns.
• Manages a team of clinical and or non-clinical personnel (clinical mgmt. for clinical staff/MRT.
• Serves as a content model expert and mentor to team in regard to Aetna's policies and procedures, regulatory and accreditation requirements.
• Manages to performance measures and standards for quality service and cost effectiveness and coaches’ team/individuals to take appropriate action. Select staff using clearly defined requirements in terms of education, experience, technical and performance skills.
• Build strong functional teams through formal training, diverse assignments, coaching, mentoring and other developmental techniques.
• Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams and individuals.
• Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turnaround time for Appeals and Complaints handling.
• Ensures all Complaints and Appeals units are utilizing the National tracking tool to ensure reporting consistency and trend analysis.
• Holds individuals/team accountable for results; recognize/reward as appropriate.
• Lead change efforts while managing transitions within a team.
• Identifies trends involving non-clinical & clinical issues and reports on and recommends solutions.
• Additional duties as assigned, (e.g., Supervisors with less than 15 direct reports will also handle resolution work the % of the time they are not managing their staff). Sedentary work involving significant periods of sitting, talking, hearing, and keying. Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor. Working environment includes typical office conditions.
• Develop denial letters that are compliant with regulations and are written in plain language to meet health literacy requirements - Assist the Learning and Education team to educate personnel about business processes, regulations, and accreditation requirements

• Coordinate external review of denials to comply with state and federal requirements, and to meet state requirements for like-specialists or specific physician state licensure
• Collaborate with internal Medical Directors and supervisors on appropriate language that is required in denial letters, including clinical rationale
• Manage member/provider calls regarding denials and reconsiderations
• Managing policies and procedures on a monthly basis and as applicable

Education and Certification Requirements

• 1-3 years supervisory experience. Experience in research and analysis of claim processing a plus.
• 3-5 years clinical experience - required for managing clinical staff (MRT). Experience working with managed and non-managed health care benefits.
• Bachelor's degree or 5 years equivalent work experience in Healthcare, Project Management, Audit, Systems Design.

Additional Information

• Strong analytical skills focusing on accuracy and attention to detail. Sound judgement.
• Product knowledge and experience with Complaints and Appeals and Regulatory Requirements.
• 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.

Pay Range

The typical pay range for this role is:

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.
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

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.