Ods C Jobs in Arizona (NOW HIRING)

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Position Summary
The Special Supplemental Benefits team has an exciting new opportunity within its operations area. As an analyst in, Medicare Product Operations, you will play a critical role in conducting thorough and timely reviews of member requests related to Medicare Advantage supplemental benefit coverage and providing an organization determination while ensuring compliance with CMS regulations and policies for Medicare Advantage supplemental benefit non-clinical organization determinations (NCOD).

Responsibilities include:

• 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.

Required Qualifications

• 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

Preferred Qualifications

• 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

Education

• High School Diploma or equivalent experience

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

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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.

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.