Member Appeals & Grievances Specialist

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking an Appeals Specialist to manage intake, investigation and resolution of appeals, complaints, and grievances across products. The role requires coordinating responses from multiple business units and ensuring timely, customer-focused resolution while identifying trends.

You will research plan designs, verify benefit descriptions, review claim processing logic, and coordinate final communications to members or providers.

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

• 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.

Skills

Benefit language research

Claims platforms

Customer service

Regulatory analysis

Data analysis

Communication

Education

Some college

High School or GED

Tools

Excel

Microsoft Word

Job description

CVS Health is seeking an Appeals Specialist to manage intake, investigation and resolution of appeals, complaints, and grievances across products. The role requires coordinating responses from multiple business units and ensuring timely, customer-focused resolution while identifying trends.

You will research plan designs, verify benefit descriptions, review claim processing logic, and coordinate final communications to members or providers.