Appeals & Grievance Specialist - Resolution & Trends

CVS Health; Virginia; On-site; USD 23,000 - 43,000; Full time

Job summary

CVS Health in Virginia is seeking an Appeals, Complaints and Grievances Specialist responsible for intake, investigation and resolution across products, coordinating responses across business units to ensure timely, customer-focused resolution.

You will research benefit language, plan design relevance, and claim processing logic to verify accuracy. The role requires strong data analysis, regulatory awareness, and clear written communication with members and providers.

Qualifications

• Experience reading or researching benefit language.
• 1-2 years experience with claim platforms, products, benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.

Responsibilities

• Research incoming appeals, complaints and grievances to determine appropriate routing.
• Research plan design or certification of coverage to determine accuracy of benefits.
• Verify claim processing logic, member eligibility, and payment status prior to initiation of appeal process.
• Coordinate all components of appeals and provide final resolution communication to member/provider.

Skills

Reading benefit language

Claim platforms experience

Regulatory analysis

Customer service

Analytical skills

Excel

Microsoft Word

Education

Some college

High School or GED

Tools

Excel

Microsoft Word

Job description

CVS Health in Virginia is seeking an Appeals, Complaints and Grievances Specialist responsible for intake, investigation and resolution across products, coordinating responses across business units to ensure timely, customer-focused resolution.

You will research benefit language, plan design relevance, and claim processing logic to verify accuracy. The role requires strong data analysis, regulatory awareness, and clear written communication with members and providers.