Appeal and Grievance Coordinator - MUST live in KY, OK, and OH

CVS Health•Work At Home-Louisiana, LA

1d•$17 - $26

About The Position

Responsible for intake, investigation, and resolution of appeals, complaints, and grievances across all products. The work may involve multiple issues and require coordinating responses from multiple business units. The coordinator ensures timely, customer-focused responses; identifies trends and emerging issues; and reports findings and recommends solutions. The role requires working effectively in a fast-paced environment with tight turnaround times, making decisions in accordance with current policies and guidelines, and maintaining collaborative working relationships. The position must be based in Kentucky, Oklahoma, or Ohio.

Requirements

Live in Kentucky, Oklahoma, or Ohio.
Experience reading or researching benefit language.
1–2 years of experience in one or more relevant areas, including claim platforms, products and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit.
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 computer systems and use Excel and Microsoft Word.
Ability to meet the demands of a fast-paced environment with tight turnaround times.
Ability to make appropriate decisions based on current policies and guidelines.
Ability to build collaborative working relationships.
High school diploma or GED equivalent.

Nice To Haves

Some college.
Experience researching and analyzing claim processing.

Responsibilities

Research incoming electronic appeals, complaints, and grievances to determine whether they are appropriate for the unit based on published business responsibilities.
Identify the correct resource and reroute work items that do not meet appeals, complaints, and grievance criteria.
Research the member’s Standard Plan Design or Certification of Coverage to determine the accuracy and appropriateness of benefit or administrative denials.
Research claim-processing logic to verify claim payment accuracy, member eligibility data, and billing or payment status before initiating the appeal process.
Identify and research all components of member or provider/practitioner appeals, complaints, and grievances across products and services.
Triage incomplete components to the appropriate subject matter experts in other business units and obtain response content for the final resolution.
Coordinate all components of appeals, complaints, and grievances, including final communication to the member or provider and case closure.
Serve as a technical resource to colleagues on appeals, complaints, and grievance issues and similar situations requiring greater expertise.
Identify and report trends and emerging issues and provide input on potential solutions.