Healthcare Appeals & Grievances Specialist

CVS Health; New Jersey; Hybrid; USD 23,000 - 43,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Other resources, based on eligibility.

Job summary

CVS Health is seeking an Appeals, Complaints and Grievances Specialist to manage intake, investigation and resolution for all products. You will coordinate responses across multiple business units, triage components to subject matter experts and ensure timely, customer-focused communication to members and providers.

Responsibilities include researching plan design, benefit language, and claim processing details to verify accuracy before final resolution.

Qualifications

• Experience in reading or researching benefit language.
• 1-2 years experience that includes 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

• Handle intake, investigation and resolution of appeals, complaints and grievances for all products.
• Coordinate responses from multiple business units.
• Identify trends and emerging issues and report solutions.
• Research incoming electronic appeals, complaints and grievance to identify appropriateness.
• Identify correct resources and reroute inappropriate work items.
• Research plan design or Certification of Coverage relevant to the member.
• Research claim processing logic to verify accuracy of claim payment and eligibility.
• Triage components to subject matter experts for final resolution content.
• Coordinate all components of appeals and final communication to member/provider.
• Serve as a technical resource regarding appeals and grievance issues.

Skills

Benefit language experience

Claims platforms experience

Education

Some college preferred

High School or GED equivalent

Job description

CVS Health is seeking an Appeals, Complaints and Grievances Specialist to manage intake, investigation and resolution for all products. You will coordinate responses across multiple business units, triage components to subject matter experts and ensure timely, customer-focused communication to members and providers.

Responsibilities include researching plan design, benefit language, and claim processing details to verify accuracy before final resolution.