Appeal and Grievance Coordinator

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🔥 0 minutes ago

🐎 Kentucky – Remote

🐎 Kentucky – Remote

💵 $17 - $25 / hour

⏰ Full Time

🟢 Junior

🚫👨‍🎓 No degree required

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Responsible for intake, investigation and resolution of appeals, complaints and grievances. • Ensure timely, customer focused response to appeals, complaints and grievance. • Identify trends and emerging issues and report and recommend solutions. • Research incoming electronic appeals, complaints and grievance to identify if appropriate. • Identify correct resource and reroute inappropriate work items. • Research Standard Plan Design or Certification of Coverage relevant to the member. • Research claim processing logic to verify accuracy of claim payment. • Identify and research all components within member or provider/practitioner appeals. • Triage incomplete components of appeals to appropriate subject matter expert. • Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues.

🎯 Requirements

• 1-2 years experience that includes but is not limited too claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience. • Experience in reading or researching benefit language. • 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. • Some college preferred. • High School or GED equivalent.

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • comprehensive benefits package