Appeal and Grievance Coordinator

Job not on LinkedIn

🔥 1 minute ago

🌪️ Oklahoma – Remote

🌪️ Oklahoma – Remote

💵 $17 - $25 / hour

⏰ Full Time

🟢 Junior

🚫👨‍🎓 No degree required

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

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

• Handle intake, investigation, and resolution of appeals, complaints, and grievances across all products • Research incoming electronic appeals, complaints, and grievances and route inappropriate work items • Research plan design or certification of coverage to assess benefit or administrative denials • Research claim processing logic, claim payment accuracy, member eligibility, and billing/payment status • Identify and research all components of member or provider/practitioner cases • Triage incomplete case components to subject matter experts in other business units • Coordinate case components, final communications, resolution, and closure • Serve as a technical resource to colleagues on appeals, complaints, and grievance issues • Identify trends and emerging issues, report findings, and recommend potential solutions

🎯 Requirements

• MUST live in OK • 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 • Experience in reading or researching benefit language • High School or GED equivalent • 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 • Some college preferred

🏖️ 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 • Full-time comprehensive benefits package

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