Appeal and Grievance Coordinator - Prefer candidate live in TX

$35,360 - $59,197/Yr

CVS Health - Austin, TX

Full-time - Entry Level

Austin, TX

Health and Personal Care Retailers

About the position

The Appeal and Grievance Coordinator at CVS Health is responsible for the intake, investigation, and resolution of appeals, complaints, and grievances across various products. This role requires a customer-focused approach to ensure timely responses and involves coordinating with multiple business units to address complex issues. The coordinator will also identify trends, research claims, and serve as a technical resource for colleagues, all while maintaining a high level of accuracy and attention to detail.

Responsibilities

• Intake, investigate, and resolve appeals, complaints, and grievances for all products.
• Ensure timely, customer-focused responses to appeals and complaints.
• Identify trends and emerging issues, reporting and recommending solutions.
• Research incoming electronic appeals to determine appropriateness based on business responsibilities.
• Identify correct resources and reroute inappropriate work items.
• Research Standard Plan Design or Certification of Coverage for accuracy of benefit denials.
• Verify accuracy of claim payments and member eligibility data before initiating appeals.
• Triage incomplete components of appeals to appropriate subject matter experts for resolution.
• Coordinate all components of appeals, including final communication to members/providers for resolution.
• Serve as a technical resource to colleagues regarding appeals and grievance issues.

Requirements

• 1-2 years of experience in claim platforms, products, and benefits; patient management; compliance and regulatory analysis; or customer service.
• Experience in reading or researching benefit language.
• Strong analytical skills with a focus on accuracy and attention to detail.
• Thorough knowledge of member and/or provider appeals, complaints, and grievance policies.
• Excellent verbal and written communication skills.
• Computer literacy, including proficiency in Excel and Microsoft Word.

Nice-to-haves

• Experience in research and analysis of claim processing.
• Some college education preferred.

Benefits

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