Appeal and Grievance Coordinator

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 and emerging issues, providing insights and recommendations for solutions.

Responsibilities

• Intake, investigate, and resolve appeals, complaints, and grievances for all products.
• Research incoming electronic appeals to determine appropriateness based on business responsibilities.
• Verify accuracy of benefit/administrative denials by researching Standard Plan Design or Certification of Coverage.
• Check claim processing logic for accuracy of claim payments and member eligibility 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 and closure.
• Serve as a technical resource for colleagues on appeals and grievance issues.
• Identify trends and emerging issues, reporting on them and providing input on potential solutions.
• Meet demands of a high-paced environment with tight turnaround times.
• Make decisions based on current policies and guidelines.

Requirements

• 1-2 years of experience in claim platforms, products, benefits, patient management, compliance, regulatory analysis, or customer service.
• 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 and free development courses.
• CVS store discount and discount programs with partners.
• Paid Time Off (PTO) and paid holidays.