Appeal and Grievance Coordinator

Job not on LinkedIn

🔥 0 minutes ago

🐎 Kentucky, New Jersey, +2 more states – Remote

🐎 Kentucky – Remote 🏖️ New Jersey – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote

💵 $17 - $31 / 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

• Intake, investigate, and resolve appeals, complaints, and grievances across all products • Research incoming electronic appeals, complaints, and grievances and route inappropriate work items • Research plan design and coverage certification to assess benefit or administrative denials • Research claim-processing logic, member eligibility, and billing/payment status before initiating appeals • Identify and research all components of member or provider appeals, complaints, and grievances • Triage incomplete components to appropriate subject-matter experts in other business units • Coordinate all appeal, complaint, and grievance components, including final communications and closure • Serve as a technical resource to colleagues on complex issues • Identify and report trends and emerging issues and provide input on potential solutions

🎯 Requirements

• Must live in KY, OK, OH • 1–2 years of 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 reading or researching benefit language • Ability to meet demands of a fast-paced environment with tight turnaround times • Ability to make appropriate decisions based on current policies/guidelines • Thorough knowledge of member and/or provider appeals, complaints, and grievance policies • Strong analytical skills with 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 • High school diploma or GED equivalent • 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

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