Combining the assets of our health insurance products and services with CVS Health's unrivaled presence in local communities and their pharmacy benefits management capabilities, we're joining members on their path to better health and transforming the health care landscape in new and exciting ways every day.
Aetna is recruiting for an Executive Director, Medicare Par Provider Appeals who is a highly skilled operational leader who oversees all appeals activities for the new Medicare Par Provider Appeals department. This leader will ensure compliance with all state and federal appeals laws, the Center for Medicare and Medicaid Services (CMS) regulations, and all applicable accrediting standards. This leader develops and implements departmental policies and procedures to ensure optimized, efficient, and compliant management of clinical and administrative appeals. They have operational expertise in developing, managing, and leading a team of clinical and administrative professionals. They will need to partner closely with the Appeals Intake COE, Medicare Member Non-Par Appeals team, Medicare Grievance and CTM team, Medicare Claims, G&A Insights and Root Cause team, Medical Policy, Medical Economics Unit, Utilization Management, Finance, and IT.
You'll make an impact by:
Responsibility for developing and implementing operational strategies and programs to ensure all production and quality measures are met.
Establishing quality processes within appeals that focus on data integrity and meet compliance requirements.
Leading participation and responding to audits (internal and external regulatory agencies).
Developing and executing internal and vendor staffing plans to ensure timely and compliant monitoring of appeals.
Partnering with key stake holders in developing high quality end-to-end business development strategies, including RFP response and proposal development.
Leading multiple clinical and administrative managers, specialized professional staff and/or outsourced operations.
Developing and implementing departmental policies, procedures, workflows incorporating new processes into existing systems and workflows while ensuring compliance with federal and state governing agencies.
Supporting development of appeals operational reports for daily, weekly, monthly monitoring.
Partnering on optimization of appeals platforms, identifies efficiency enhancements and collaborates with IT and vendor for implementation.
P&L oversight for Medicare Appeals department.
Serving as an organizational Medicare appeals SME and communicates & collaborates effectively with other department leaders ie. Actuary, Network, Market, IT, Analytics.
Ensuring quality oversight team within Medicare appeals and coordinates with CVS internal auditing team.
Instilling a culture of accountability and ownership; builds strong teams through the development of leaders.
Supporting CVS Health in attracting, retaining, and engaging a diverse and inclusive consumer-centric workforce that delivers on our purpose and reflects the communities in which we work, live, and serve.
The candidate will have a strong work ethic, be a self-starter, and be able to be highly productive in a dynamic, collaborative environment. This position offers broad exposure to all aspects of the company's business, as well as significant interaction with all the business leaders. The candidate will be expected to have the following key attributes:
10+ years' experience in health plan operations management required.
Knowledge of all types of managed care products including HMO, PPO, and Medicare Part D.
Previous appeals experience preferred.
Experience with business process development, implementations, migrations, system updates, or operational improvements is required.
Strong analytical skillset with experience directing reporting and analytics.
Ability to work Hybrid Model (in office Tuesday / Wednesday / Thursday).
Demonstrated a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.
Bachelor's Degree required. Clinical degree preferred
The typical pay range for this role is:
$131,500.00 - $303,200.00
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
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through [email protected] If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.