Appeals & Grievances Specialist

CVS Health; Frankfort (KY); On-site; USD 23,000 - 43,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a dedicated Appeals Specialist to manage intake, investigation and resolution of member appeals and grievances. You will coordinate across clinical and operations units to deliver timely, accurate responses, identify trends, and propose solutions.

Strong analytical skills and knowledge of benefits language are essential. Responsibilities include researching benefit language and plan design, verifying claim data, and ensuring compliance with policies while communicating

Qualifications

• Experience in reading or researching benefit language.
• 1-2 years experience in claim platforms, products and benefits; patient management; compliance and regulatory analysis; customer service or audit experience.

Responsibilities

• Intake, investigation and resolution of appeals, complaints and grievances for all products.
• Coordinate responses from multiple business units to ensure timely customer-focused resolutions.
• Research benefit language, plan design and coverage relevance to determine accuracy of denials or approvals.
• Verify claim payment, member eligibility data and billing status prior to initiating appeals.
• Identify trends and report on potential solutions to improve processes.
• Coordinate all components of appeals and provide final communication to members/providers.
• Serve as a technical resource to colleagues on appeals and grievance issues.
• Meet demands of a high-paced environment with tight turnaround times.
• Adhere to current policies and regulatory guidelines, maintaining accuracy and attention to detail.

Skills

Benefit language

Claims processing

Regulatory analysis

Customer service

Education

Some college preferred

High School or GED equivalent

Tools

Excel

Microsoft Word

Job description

CVS Health is seeking a dedicated Appeals Specialist to manage intake, investigation and resolution of member appeals and grievances. You will coordinate across clinical and operations units to deliver timely, accurate responses, identify trends, and propose solutions.

Strong analytical skills and knowledge of benefits language are essential. Responsibilities include researching benefit language and plan design, verifying claim data, and ensuring compliance with policies while communicating