Appeal and Grievance Coordinator - MUST live in OK

CVS Health•Work At Home-Oklahoma, OK

1d•$17 - $26

About The Position

The Appeal and Grievance Coordinator is responsible for intake, investigation, and resolution of appeals, complaints, and grievances across all products. Cases may involve multiple issues and require coordination of responses across business units. The coordinator ensures timely, customer-focused resolutions, identifies trends and emerging issues, and reports findings and recommends potential solutions. This role must be performed by someone who lives in Oklahoma. The coordinator researches incoming cases, benefit and coverage language, claim-processing logic, eligibility, and billing or payment status. They identify and route work items to the appropriate resources, coordinate input from subject matter experts, and manage all case components through final communication and closure. The role also serves as a technical resource to colleagues and requires sound decisions under current policies and guidelines, accuracy, collaboration, and the ability to work in a fast-paced environment with tight turnaround times.

Requirements

Must live in Oklahoma.
Experience reading or researching benefit language.
1–2 years of experience in areas such as claim platforms, products and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or auditing.
Thorough knowledge of member and/or provider appeals, complaints, and grievance policies.
Strong analytical skills, accuracy, and attention to detail.
Knowledge of clinical terminology and regulatory and accreditation requirements.
Excellent verbal and written communication skills.
Computer literacy, including the ability to navigate internal and external systems and use Excel and Microsoft Word.
Ability to work in a fast-paced environment with tight turnaround times and maintain collaborative working relationships.

Nice To Haves

Some college is preferred.
Experience researching and analyzing claim processing is a plus.

Responsibilities

Intake, investigate, and resolve appeals, complaints, and grievances across products, coordinating responses across business units when needed.
Research incoming electronic cases to determine whether they belong to the unit and reroute inappropriate work items to the correct resource.
Review plan design or certificate-of-coverage language to assess benefit or administrative denials.
Research claim-processing logic, member eligibility, and billing or payment status before beginning the appeal process.
Identify and investigate all components of member or provider appeals, complaints, and grievances.
Refer incomplete case components to appropriate subject matter experts for resolution content.
Coordinate all case components and provide final resolution communications to members or providers through closure.
Serve as a technical resource to colleagues on appeals, complaints, grievances, and related complex situations.
Identify and report trends and emerging issues and provide input on potential solutions.
Make appropriate decisions based on current policies and guidelines while meeting tight turnaround times.