Senior Manager - Complaint & Appeals

Position Summary

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

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.
• 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.
• Builds strong functional teams through formal training, diverse assignments, coaching, mentoring and other developmental techniques.
• Affirms 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.
• Maintains 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.
• Leads change efforts while managing transitions within a team.
• Identifies trends involving non-clinical & clinical issues and reports on and recommends solutions.

Preferred Qualifications

• Strong analytical skills focusing on accuracy and attention to detail.
• Sound judgement.
• 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.