Strategic Appeals & Grievances Specialist

CVS Health; West Virginia; Hybrid; USD 23,000 - 43,000; Full time

Job summary

CVS Health is seeking an Appeals Specialist to handle intake, investigation and resolution of appeals, complaints and grievances for multiple products. You will coordinate responses from several business units to ensure timely, customer-focused outcomes and identify trends for improvement.

Responsibilities include researching plan design/coverage, verifying claim processing logic, routing items to experts, and communicating final resolutions to members and providers.

Qualifications

• Experience in reading or researching benefit language.
• 1-2 years experience across claim platforms, products, benefits, patient management, compliance or audits.

Responsibilities

• Research incoming appeals, complaints and grievances to determine routing to the correct unit.
• Verify accuracy of benefit design or certification of coverage relevant to the member.
• Research claim processing logic to ensure proper payment, eligibility and status.
• Coordinate components of appeals and provide final resolution communication to members/providers.
• Serve as a technical resource on appeals, complaints and grievance issues.

Skills

Benefit language reading

Claim platforms knowledge

Excel

Microsoft Word

Education

Some college

High School or GED

Tools

Excel

Microsoft Word

Job description

CVS Health is seeking an Appeals Specialist to handle intake, investigation and resolution of appeals, complaints and grievances for multiple products. You will coordinate responses from several business units to ensure timely, customer-focused outcomes and identify trends for improvement.

Responsibilities include researching plan design/coverage, verifying claim processing logic, routing items to experts, and communicating final resolutions to members and providers.