[Hiring] Appeal and Grievance Coordinator @CVS Health

Role Description

Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and may require coordination of responses from multiple business units. Ensure timely, customer-focused response to appeals, complaints and grievances. Identify trends and emerging issues and report and recommend solutions.

• Research incoming electronic appeals, complaints and grievances to identify if appropriate for unit based upon published business responsibilities.
• Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.
• Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
• Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
• Identify and research all components within member or provider/practitioner appeals, complaints and grievances for all products and services.
• Triage incomplete components of appeals, complaints and grievances 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 grievances 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.
• Identifies trends and emerging issues and reports on and gives input on potential solutions.
• 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.

Qualifications

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

Preferred Qualifications

• Experience in research and analysis of claim processing a plus.

Education

• Some college preferred.
• High School or GED equivalent.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $17.00 - $25.65. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

Benefits

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include:

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility

Company Description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.