Medicaid Appeals And Grievance Associate Manager in La Work From Home

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. Position Summary Risk Management is charged with protecting company assets. This group is responsible for minimizing risk – in legal, financial and operational areas – and its affects on the organization, as well as for enforcing security and safety measures. Coordinate effective resolution of member and/or provider/practitioner appeals, complaints and grievances. Responsible for the day-to-day management of staff to ensure effective resolution of member or provider/practitioner appeals, complaints and grievances for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Responsible for day-to-day implementation of Aetna's appeals, complaints and grievances policies and procedures. Identifies trends and issues; reports on and recommends solutions. Accountable for meeting the financial, operational, and quality objectives of the unit. -Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns. -Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation req

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. Position Summary: Ready to take your Medical Director career to the next level with a Fortune 6 company? Join Aetna, a CVS Health company, and make a meaningful impact on the health and well-being of Medicaid members across the country. Aetna operates Medicaid managed care plans in Arizona, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and West Virginia. We are seeking a Medical Director to join our centralized Medical Management team. This work-from-home position will primarily support Aetna Better Health of Louisiana , while also providing support across the other health plans as needed. In this role, you will partner with Medical Management staff to ensure timely, consistent, and clinically sound decisions for members and providers. Key responsibilities include: Utilization Management and medical necessity reviews Prior authorization and precertification determinations Concurrent review for inpatient and outpatient services Acute and post-acute care reviews Peer-to-peer consultations with treating providers Pharmacy reviews and first-level appeal determinations Collaboration with multidisciplinary clinical and operational teams The Medical Director also participates in a rotating on-c