The Health Care Benefits (HCB) business is committed to helping our members achieve their best health in an affordable, convenient, and comprehensive manner. 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.

The Vice President of Aetna Grievance & Appeals will report to the Senior Vice President of Aetna Clinical Solutions and support business segments across the Aetna Health Care Business within CVS Health. This role is responsible for over 1200 clinical and non-clinical colleagues supporting over 24 million members across our Government, Commercial, and Individual health plans. This role will lead day to day operations across critical grievance and appeals functions, which serve as the conscience of the health plan and driving force for root cause analysis and process improvement to directly impact the member and provider experience.

You'll make an impact by:

• Playing a critical leadership role in developing business strategy and collaborating with our P&L and shared services leaders.
• Setting stretch goals that improve member and provider experience by having a thorough understanding of the end-to-end healthcare business model, co-dependencies that exist and the development of proactive insights. Identifying gaps with people, processes and technology that drive member and provider abrasion.
• Collaborating with Government and Commercial line of business leadership on insights and trends identified through processing grievances & appeals that pertain to benefit discrepancies and concerns from members.
• Developing, implementing and providing oversight of CMS and state regulatory guidance requirements for grievance and appeals for HCB lines of business.
• Developing and leading cross-functional governance and management process with Operations, Product, Clinical, Vendor and Executive teams to determine areas of improvement.
• Serving as Aetna’s Health Care Business voice with National Committee for Quality Assurance, Centers for Medicare & Medicaid Services, Department of Health, Utilization Review Accreditation Commission, Department of Labor, and Department of Financial Service plus the Attorney General.
• Delivering operations in the most efficient and compliant manner.

LOCATION: Hartford, CT, Woonsocket, RI or Remote

Pay Range
The typical pay range for this role is:
Minimum: 250,000
Maximum: 350,000

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications

• Strong operational leader with 10+ years managed care experience and knowledge of Grievances and Appeals
• Experience interpreting and implementing federal, state and local guidelines for all aspects of member and provider processes
• Working knowledge of Medicare and Medicaid regulations
• Experience leveraging root cause analysis and process improvement methodology to improve member & provider experience
• Strong people leader
• Experience managing clinicians highly valued
• Experience in the development and implementation of metrics and analytics to measure performance
• Must be strategic but also very comfortable in the details
• Proven experience leveraging technology to improve efficiencies; experience consolidating and optimizing tech platforms will be highly valued

COVID Requirements

COVID-19 Vaccination Requirement
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.

Preferred Qualifications

• Advanced Degree
• Six Sigma

Education

• Bachelor's Degree

Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.