Description
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. 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* Responsible for intake of provider disputes from all Mercy Care lines of business. *Required Qualifications* -Research incoming electronic disputes/appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet disputes/appeal criteria. -Research Plan Sponsor claim fiduciary responsibility, assemble data used in making the denial determination, assemble, summarize and send to Plan Sponsor contact. -Research Standard Plan Design or Certification of Coverage pertinent 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 complaints/appeals for all products and services. -Triage incomplete components of disputes/appeals 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 disputes/appeals including final communication to provider via phone on status updates/Notice of decisions. -Serve as a technical resource to colleagues on claim research, email content, state or federal regulatory language, triaging of dispute/appeal issues, and similar situations requiring a higher level of expertise. -Identifies trends and emerging issues and reports on and gives input on potential solutions. Follow up to assure dispute/appeal is handled within established timeframe to meet company and regulatory requirements. --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 provider appeal 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. -Work in office when necessary to cover mail. *Preferred Qualifications* -Experience in reading or researching benefit language. -1-2 years' experience that includes but is not limited to claim platforms, products, and benefits; patient management; compliance and regulatory analysis; customer service or audit experience. Preferred Qualifications : -Experience in research and analysis of claim processing a plus *Education* High School diploma or GED. *Pay Range* The typical pay range for this role is: $17.00 - $28.45This 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](https://jobs.cvshealth.com/benefits) We anticipate the application window for this opening will close on: 05/12/2024
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