Appeal and Grievance Coordinator - MUST live in KY,

CVS Health•Work At Home-Kentucky, VA

1d•$17 - $31

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 from multiple business units. The coordinator ensures timely, customer-focused responses, identifies trends and emerging issues, and reports on and recommends potential solutions. The position requires living in Kentucky and working in a fast-paced environment with tight turnaround times.

Requirements

Must live in Kentucky.
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 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 to navigate internal and external systems, including Excel and Microsoft Word.
Ability to meet the demands of a fast-paced environment with tight turnaround times.
Ability to build collaborative working relationships.

Nice To Haves

Experience researching and analyzing claim processing.
Some college education.

Responsibilities

Research incoming electronic appeals, complaints, and grievances to determine whether they belong to the unit and reroute items that do not meet the unit’s responsibilities or case criteria.
Review the member’s Standard Plan Design or Certification of Coverage to assess the accuracy and appropriateness of benefit or administrative denials.
Research claim-processing logic, 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.
Refer incomplete case components to appropriate subject matter experts in other business units and coordinate their 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, grievances, and similar issues requiring a higher level of expertise.
Identify and report trends and emerging issues and provide input on potential solutions.
Make appropriate decisions based on Aetna’s current policies and guidelines.