Appeals & Grievance Resolution Specialist

CVS Health; United States; Remote; USD 23,000 - 36,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health in the United States is seeking a specialist to manage intake, investigation, and resolution of appeals, complaints, and grievances across products. You will coordinate with multiple units to ensure timely, customer-focused responses and identify trends to inform process improvements.

Strong analytical skills and knowledge of benefit language, claim processing, and regulatory requirements are essential.

Qualifications

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

Responsibilities

• Intake, investigation and resolution of appeals, complaints and grievances scenarios for all products; coordinate responses from multiple units.
• Research incoming electronic appeals, complaints and grievances to route appropriately.
• 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 to appropriate SME within another unit for resolution content.
• Coordinate all components of appeals including final communication to member/provider for final resolution and closure.
• Serve as a technical resource to colleagues regarding appeals and grievances issues.

Skills

Research skills

Analytical thinking

Verbal communication

Written communication

Education

Some college

High School or GED

Tools

Excel

Microsoft Word

Job description

CVS Health in the United States is seeking a specialist to manage intake, investigation, and resolution of appeals, complaints, and grievances across products. You will coordinate with multiple units to ensure timely, customer-focused responses and identify trends to inform process improvements.

Strong analytical skills and knowledge of benefit language, claim processing, and regulatory requirements are essential.