Appeal and Grievance Coordinator - MUST live in FL

CVS Health • Tallahassee, FL

412d • $35,360 - $53,352

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 focus on timely and customer-oriented responses, coordination with multiple business units, and the ability to identify trends and recommend solutions. The position is remote but requires candidates to reside in Florida.

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.
• 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 is a plus.
• Some college education preferred.

Responsibilities

• Intake, investigate, and resolve appeals, complaints, and grievances for all products.
• Ensure timely, customer-focused responses to appeals, complaints, and grievances.
• Identify trends and emerging issues, reporting and recommending solutions.
• Research incoming electronic appeals, complaints, and grievances to determine appropriateness for the unit.
• Identify correct resources and reroute inappropriate work items that do not meet criteria.
• Research Standard Plan Design or Certification of Coverage to determine accuracy of benefit/administrative denial.
• Verify accuracy of claim payment, member eligibility data, and billing/payment status before initiating the appeal process.
• Triage incomplete components of appeals, complaints, and grievances to appropriate subject matter experts for resolution.
• Coordinate all components of appeals, complaints, and grievances, including final communication to members/providers for resolution and closure.
• Serve as a technical resource to colleagues regarding appeals, complaints, and grievance issues.
• Collaborate effectively with various business units to ensure comprehensive resolution of issues.

Benefits

• Full range of medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Employee Stock Purchase Plan for eligible employees.
• Fully-paid term life insurance plan for eligible employees.
• Short-term and long-term disability benefits.
• Numerous well-being programs.
• Education assistance and free development courses.
• CVS store discount and discount programs with participating partners.
• Paid Time Off (PTO) and paid holidays throughout the calendar year.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Health and Personal Care Retailers
• Education Level: High school or GED