Grievance Resolution & Appeals Specialist

CVS Health; Central City (KY); On-site; USD 23,000 - 35,000; Full time

Benefits offered by this job

Medical insurance

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking an Appeals, Complaints and Grievances specialist in Kentucky to manage intake, investigate, and resolve appeals and grievances across multiple products. You will coordinate responses from several business units to ensure timely, customer-focused outcomes.

You will research benefit language, plan design, and claim processing logic to verify accuracy, triage issues to experts, and act as a technical resource. Strong communication and regulatory knowledge are essential.

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.

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 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 thinking

Communication skills

Regulatory knowledge

Clinical terminology

Education

Some college preferred.

High School or GED equivalent.

Tools

Excel

Microsoft Word

Job description

CVS Health is seeking an Appeals, Complaints and Grievances specialist in Kentucky to manage intake, investigate, and resolve appeals and grievances across multiple products. You will coordinate responses from several business units to ensure timely, customer-focused outcomes.

You will research benefit language, plan design, and claim processing logic to verify accuracy, triage issues to experts, and act as a technical resource. Strong communication and regulatory knowledge are essential.