Coordinator, Complaint & Appeals Operations

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🔥 0 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $17 - $28 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

⚙️ Operations

🚫👨‍🎓 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 scenarios for all products. • 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 for unit based upon published business responsibilities. • Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. • Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services. • Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response. • Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure. • Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise. • 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 in order to navigate through internal/external computer systems, including Excel and Microsoft Word.

🎯 Requirements

• Experience in reading or researching benefit language. • 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.

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • other resources, based on eligibility