Medicare Product Operations Analyst

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.

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.

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