[Hiring] Sr Appeal and Grievance Coordinator @CVS Health

Role Description

Coordinate effective resolution of member or provider/practitioner appeals. Responsible for managing to resolution of appeals, complaints and grievances scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. May have contact with outside plan sponsors or regulators.

• Research and resolve incoming electronic appeals, complaints and grievances as appropriate as a “single-point-of-contact” based on type of case.
• Identify and reroute inappropriate work items that do not meet appeal, complaint and grievance criteria as well as identify trends in misrouted work.
• Assemble all data used in making denial determinations and act as subject matter expert with regards to unit workflows, appeals, complaints and grievances processes and procedures.
• Review a clinical determination and understand rationale for decision.
• Research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process.
• Serve as point person for newer staff in answering questions associated with claims/customer service systems and products.
• Educate team mates as well as other areas on all components within member or provider/practitioner appeals, complaints and grievances for all products and services.
• Coordinate efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of appeals, complaints and grievances, and similar situations requiring a higher level of expertise.
• Identify trends and emerging issues and report on and give input on potential solutions.
• Deliver internal quality reviews, provide appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required.
• Understand and respond to ERT/SMRT/DOI/BBB appeals, complaints and grievances.

Qualifications

• Excellent written and oral communication skills.
• Ability to work cross organizationally.
• Strong analytical skills focusing on accuracy and attention to detail.

Requirements

• Experience in reading or researching benefit language.
• Experience in research and analysis of claim processing a plus.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• Ability to maintain accuracy and production standards.

Education

• Associate's degree or equivalent work experience.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.