Appeals & Grievances Specialist—Impactful Resolution

CVS Health; Ohio; On-site; USD 23,000 - 35,000; Full time

Job summary

CVS Health in Ohio seeks a specialist to handle intake, investigation and resolution of appeals, complaints and grievances across multiple products. You will coordinate responses from multiple business units and ensure timely, customer-focused communication to members and providers.

Strong analytical abilities and knowledge of regulatory requirements are essential. The role requires 1-2 years in related areas and proficiency with claim platforms, benefits, and contracts; high school diploma or

Qualifications

• Experience in reading or researching benefit language.
• 1-2 years experience in claim platforms, products, and 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

• 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 reports on and gives input on potential solutions.

Skills

Analytical skills

Communication skills

Regulatory knowledge

Attention to detail

Clinical terminology

Education

High School diploma or GED

Some college preferred

Tools

Excel

Microsoft Word

Job description

CVS Health in Ohio seeks a specialist to handle intake, investigation and resolution of appeals, complaints and grievances across multiple products. You will coordinate responses from multiple business units and ensure timely, customer-focused communication to members and providers.

Strong analytical abilities and knowledge of regulatory requirements are essential. The role requires 1-2 years in related areas and proficiency with claim platforms, benefits, and contracts; high school diploma or