Complaint & Appeal Coordinator

4004 Aetna Medicaid Administrators; New Jersey; Hybrid; USD 48,712,000 - 89,687,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Job summary

CVS Health is seeking a detail-oriented professional to manage intake, investigation, and resolution of appeals, complaints and grievances across multiple products. You will identify trends, coordinate responses, and ensure timely, customer-focused outcomes.

Responsibilities include researching benefit language, plan design and processing logic to verify accuracy before final resolutions, collaborating with subject matter experts, and maintaining high-quality service in a fast-paced environment.

Qualifications

• Experience reading or researching benefit language.
• 1-2 years experience across claims, products, and benefits; patient management, compliance, or audit work.

Responsibilities

• Handle intake, investigation and resolution of appeals, complaints and grievances.
• Identify trends and escalate issues across units.
• Coordinate responses from multiple business units to finalize communications.
• Research plan design or coverage to verify benefit/administrative denials.
• Ensure accurate claim processing and member eligibility before final resolution.

Skills

Analytical skills

Verbal and written communication

Regulatory knowledge

Education

Some college

High School or GED

Tools

Excel

Microsoft 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 reports on and gives input on potential 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 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of 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.

We anticipate the application window for this opening will close on: 10/31/2026 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.