Note: The job is a remote job and is open to candidates in USA. CVS Health is a health care company focused on creating a more connected, convenient, and compassionate health experience. The Medicare Product Operations Analyst reviews Medicare Advantage supplemental benefit coverage requests, makes and communicates organization determinations, maintains compliant documentation, and supports appeals, grievances, implementation, and process improvement activities.
Responsibilities
- Leverage workflows, tools, processes and procedures for effective analysis, interpretation, and processing of NCODs for Medicare Supplemental Benefits
- Review requests for supplemental benefit coverage, make determinations based on benefit coverage guidelines, communicate those decisions (positive or negative) to members and ensure proper documentation of the decisions within established timeframes in accordance with regulatory requirements and internal policies. This may include analyzing claims data, eligibility files, plan benefit information, etc. to determine if an approval or denial is appropriate based upon supplemental benefit coverage, policies and applicable regulations
- Outreach members or providers to explain OD decisions and provide care management referrals
- Use letter templates to send clear and concise organization determination letters, explaining in plain language the rationale behind the decision and citing relevant policies and regulations
- Ensure compliance with all CMS/Medicare organization determination (OD) requirements and any other CMS guidance related to ODs, appeals or grievances
- Maintaining accurate and detailed records of all NCODs and associated notes, documentation, correspondence and final determinations ensuring compliance with regulatory requirements
- Review and respond to appeals and grievances inquiries related to coverage decisions
- Collaborates with other departments/teams, such as claims processing, eligibility, appeals, grievances, compliance and/or vendor partners, to gather information and resolve member requests for coverage and ensure NCOD compliance
- Stay up to date on changes in Medicare regulations and plan policies
- Supporting any OD related special projects as needed
- Identifies areas of improvement and coordinates key tasks with relevant stakeholders to develop comprehensive action plans
- Promotes and advances a culture of continuous improvement within the organization
- Additionally, this position may partner and/or support various implementation and operational activities, as assigned
Skills
- 3+ years of experience in Medicare Advantage in any area such as: product, appeals, compliance or operations with familiarity of Part C coverage and benefits
- 1+ years with Medicare rules, regulations and standards, including compliance requirements
- Strong interpersonal skills and the ability to work independently and collaborate across boundaries
- Strong written and verbal communication skills
- Ability to analyze data, assess situations and develop recommendations for process improvements
- Self-starter who can work independently and in a matrixed environment
- Proficient and comfortable with navigating Microsoft Office products (Excel, Word, and Outlook) and other computer-based applications/programs
- Proficient in Medicare business applications such as GPS, STARS Central, QNXT, and Medcompass
- Highly organized and detail oriented along with having strong time management, priority, and problem-solving skills
- Candidates must be flexible to meet the changing needs of the business
- High School Diploma or equivalent experience
- Relevant experience in coverage determination or appeals management
- Customer service experience. Keeping customer centered approach to problem solving and communicating while keeping business objectives and goals in-mind
- Bachelor's degree
Benefits
- Eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
Company Overview