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Job Information

CVS Health Claims Dispute Manager in Phoenix, Arizona

Job Description

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.

Fundamental Components

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 regards 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 turn around 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.

Background Experience

  • Experience in research and analysis of claim processing a plus.

  • 1-3 years supervisory experience.

  • 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 Job 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.

Education

High School diploma, G.E.D. or equivalent experience

Percent of Travel Required

0 - 10%

Business Overview

Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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