Complaint & Appeal Coordinator

Job not on LinkedIn

🔥 0 minutes ago

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $17 - $31 / hour

⏰ Full Time

🟢 Junior

🚫👨‍🎓 No degree required

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 for all products • Coordinate responses from multiple business units for cases containing multiple issues • Research incoming electronic cases and route inappropriate work items • Research plan designs and coverage certifications to determine benefit or administrative denial accuracy • Research claim processing logic, member eligibility data, 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 • Coordinate case components, final communications, resolution, and closure • Serve as a technical resource to colleagues on appeals, complaints, and grievance issues • Identify and report trends and emerging issues and recommend potential solutions

🎯 Requirements

• High School or GED equivalent • 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 • 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 • Experience in research and analysis of claim processing a plus

🏖️ 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