Appeal and Grievance Coordinator - MUST live in KY,

CVS Health; Kentucky; Hybrid; USD 23,000 - 43,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Retirement savings

Paid time off

Job summary

CVS Health is seeking an Appeals Specialist to manage intake, investigation and resolution of appeals, complaints and grievances across products. You will coordinate responses from multiple units to ensure timely, customer-focused resolution and identify trends to inform improvements.

The role requires strong analytical skills, familiarity with benefit language and policy guidance, and proficiency with Excel/Word.

Qualifications

• Experience reading or researching benefit language.
• 1-2 years experience in claims or benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.
• Experience in research and analysis of claim processing is a plus.

Responsibilities

• Handle intake, investigation and resolution of appeals and grievances.
• Coordinate responses from multiple business units.
• Identify trends and report solutions to improve processes.
• Serve as a technical resource on appeals issues.

Skills

Analytical skills

Verbal communication

Written communication

Attention to detail

Excel

Word processing

Education

Some college or equivalent

High School diploma or GED

Tools

Excel

Word

Job description

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

Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios 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. Identify trends and emerging issues and report and recommend solutions.

• Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities.
• Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.
• Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
• Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
• Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.
• Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response.
• Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure.
• Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise.
• Identifies trends and emerging issues and report and recommend solutions.
• Ability to meet demands of a high paced environment with tight turnaround times.
• Ability to make appropriate decisions based upon Aetna's current policies/guidelines.
• Collaborative working relationships.
• Thorough knowledge of member and/or provider appeals, complaints and grievance policies.
• Strong analytical skills focusing on accuracy and attention to detail.
• Knowledge of clinical terminology, regulatory and accreditation requirements.
• Excellent verbal and written communication skills.
• Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.

Required Qualifications

• Experience in reading or researching benefit language.
• 1-2 years experience that includes but is not limited too claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.

Preferred Qualifications

• Experience in research and analysis of claim processing a plus.

Education

• Some college preferred.
• High School or GED equivalent.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range

• The typical pay range for this role is: $17.00 - $31.30

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

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.

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.