Medicaid A&G Sr. Manager

CVS Health; United States; Remote; USD 67,000 - 191,000; Full time

Job summary

CVS Health seeks a Risk Management supervisor to oversee team operations focused on member and provider complaints. The role requires strong management skills and experience in healthcare. The position offers a competitive salary and extensive benefits, including medical, dental, and vision care.

Benefits

Health insurance

401(k) retirement plan

Paid Time Off (PTO)

Employee discount programs

Education assistance

Qualifications

• 1-3 years supervisory experience.
• 3-5 years experience in appeals and grievances.
• Experience in managing healthcare benefits.

Responsibilities

• Manage teams and resources to resolve member complaints.
• Ensure compliance with legislative and accreditation requirements.
• Build and mentor high-performing teams.

Skills

Supervisory Skills

Problem Solving

Communication

Education

Bachelor's degree or equivalent work experience

Job 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

Risk Management is charged with protecting company assets. This group is responsible for minimizing risk – in legal, financial and operational areas – and its affects on the organization, as well as for enforcing security and safety measures.

Coordinate effective resolution of member or provider/practitioner appeals, complaints and grievances.

Establish and Maintain in collaboration with all segments and business units, consistent policies and procedures defining the administration and resolution of appeals, complaints and grievances from Aetna member and providers compliant with legislative, regulatory and accreditation requirements for all plans in the region. 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.

-Manages and teams productivity and resources within the region, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of concerns.
-Manages a team of clinical and or non-clinical personnel.
-Serves as a content model expert and mentor to teams for each plan in the region 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 individuals/team/region 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 hig44h performing individuals, teams and the region.
-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.
-Ensures all appeals, complaints and grievances 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

Required Qualifications

1-3 years supervisory experience
3-5 years A&G experience

Preferred Qualifications
Experience in research and analysis of claim processing a plus
Experience working with managed and non-managed health care benefits.
Medicaid experience

Education

Bachelor's degree or 5 years equivalent work experience in Healthcare, Project Management, Audit, Systems Design.

Pay Range

The typical pay range for this role is:

$67,900.00 - $190,700.00

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

Risk Management is charged with protecting company assets. This group is responsible for minimizing risk – in legal, financial and operational areas – and its affects on the organization, as well as for enforcing security and safety measures.

Coordinate effective resolution of member or provider/practitioner appeals, complaints and grievances.

Establish and Maintain in collaboration with all segments and business units, consistent policies and procedures defining the administration and resolution of appeals, complaints and grievances from Aetna member and providers compliant with legislative, regulatory and accreditation requirements for all plans in the region. 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.

-Manages and teams productivity and resources within the region, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of concerns.
-Manages a team of clinical and or non-clinical personnel.
-Serves as a content model expert and mentor to teams for each plan in the region 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 individuals/team/region 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 hig44h performing individuals, teams and the region.
-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.
-Ensures all appeals, complaints and grievances 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

Required Qualifications

1-3 years supervisory experience
3-5 years A&G experience

Preferred Qualifications
Experience in research and analysis of claim processing a plus
Experience working with managed and non-managed health care benefits.
Medicaid experience

Education

Bachelor's degree or 5 years equivalent work experience in Healthcare, Project Management, Audit, Systems Design.

Pay Range

The typical pay range for this role is:

$67,900.00 - $190,700.00

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. This position also includes an award target in the company’s equity award program.

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

We anticipate the application window for this opening will close on: 08/16/2024

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

About the company

At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.

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