Appeal and Grievance Coordinator - Prefer candidate live in TX

$35,360 - $59,197/Yr

CVS Health - Austin, TX

Full-time - Entry Level

Remote - Austin, TX

Health and Personal Care Retailers

About the position

The Appeal and Grievance Coordinator is responsible for the intake, investigation, and resolution of appeals, complaints, and grievances across various products. This role requires coordination with multiple business units to ensure timely and customer-focused responses. The coordinator will identify trends, report issues, and recommend solutions while maintaining a high level of accuracy and attention to detail in a fast-paced environment.

Responsibilities

• Research incoming electronic appeals, complaints, and grievances to determine appropriateness for the unit based on published business responsibilities.
• Identify correct resources 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 of benefit/administrative denial.
• Verify accuracy of claim payment, member eligibility data, and billing/payment status prior to initiating the 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 experts for resolution response content.
• Coordinate all components of appeals, complaints, and grievances including final communication to member/provider for resolution and closure.
• Serve as a technical resource to colleagues regarding appeals, complaints, and grievance issues.
• Identify trends and emerging issues and report on potential solutions.
• Meet demands of a high-paced environment with tight turnaround times.

Requirements

• 1-2 years of experience in 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.

Nice-to-haves

• Experience in research and analysis of claim processing.

Benefits

• Medical, dental, and vision benefits
• 401(k) retirement savings plan
• Employee Stock Purchase Plan
• Fully-paid term life insurance
• Short-term and long-term disability benefits
• Well-being programs
• Education assistance
• Free development courses
• CVS store discount
• Paid Time Off (PTO)
• Paid holidays