Senior Manager - Complaint & Appeals

4004 Aetna Medicaid Administrators; Oklahoma; On-site; USD 68,000 - 149,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Other resources

Job summary

CVS Health is seeking a program-savvy leader in Oklahoma to coordinate the resolution of member and provider appeals, complaints, and grievances. You will develop and maintain policies in collaboration with business units, ensuring compliant resolution across plans in the region.

The role requires 1-3 years of supervisory experience and 3-5 years of A&G experience, with strong analytical and communication skills to drive quality service and regulatory compliance.

Qualifications

• Strong analytical skills focusing on accuracy and attention to detail.
• Excellent verbal and written communication skills.
• Additional duties as assigned; 1-3 years supervisory experience.
• 3-5 years A&G experience.

Responsibilities

• Coordinate effective resolution of member or provider appeals, complaints and grievances.
• Establish and maintain policies and procedures for administration and resolution of appeals, complaints and grievances.
• Ensure compliance with regulatory and accreditation requirements across plans in the region.

Skills

Analytical skills

Verbal communication

Written communication

Supervisory experience

Education

Bachelor's degree or 5 years equivalent experience in Healthcare/PM/Audit/Systems Design

Job description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

MUST LIVE IN OKLAHOMA

Position Summary

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.

Required Qualifications

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

MUST RESIDE IN OKLAHOMA PER STATE REQUIREMENT

Preferred Qualifications

Strong analytical skills focusing on accuracy and attention to detail. Sound judgement. Product knowledge and experience with appeals, complaints and grievances 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 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 - $149,328.00. 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.

Benefits

• medical coverage
• dental coverage
• vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility

Great benefits for great people. We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. Additional details about available benefits are provided during the application process and on Benefits Moments.

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

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.