Senior Manager - Complaint & Appeals

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.

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 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

• 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.

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

The typical pay range for this role is: