Appeal and Grievance Coordinator

Job not on LinkedIn

🔥 22 minutes ago

🐎 Kentucky, Ohio, +1 more states – Remote

🐎 Kentucky – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote

💵 $17 - $25 / hour

⏰ Full Time

🟢 Junior

🚫👨‍🎓 No degree required

👻 Ghost score 0%

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Intake, investigate, and resolve appeals, complaints, and grievances for all products • Research incoming electronic appeals, complaints, and grievances and route inappropriate work items • Research plan design or certification of coverage to determine benefit or administrative denial accuracy • Research claim processing logic, claim payment, member eligibility, and billing/payment status • Identify and research all components of member or provider/practitioner appeals, complaints, and grievances • Triage incomplete components to subject matter experts in other business units • Coordinate all components, including final communication to members/providers and resolution closure • Serve as a technical resource to colleagues on appeals, complaints, and grievance issues • Identify trends and emerging issues, report findings, and provide input on potential solutions

🎯 Requirements

• Must live in KY, OK, and OH • 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, including Excel and Microsoft Word • Experience in reading or researching benefit language • 1–2 years experience including claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience • High School or GED equivalent

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility

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