Appeal and Grievance Coordinator - MUST live in OK

CVS Health • Milesburg, PA

9d • $17 - $26

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions.

Requirements

• Experience in reading or researching benefit language.
• 1-2 years experience that includes but is not limited too claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.

Nice To Haves

• Experience in research and analysis of claim processing a plus.

Responsibilities

• Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.
• Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
• Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
• Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.
• Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response.
• Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure.
• Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise.
• Identifies trends and emerging issues and reports on and gives input on potential solutions.
• Ability to meet demands of a high paced environment with tight turnaround times.
• Ability to make appropriate decisions based upon Aetna's current policies/guidelines.
• Collaborative working relationships.
• Thorough knowledge of member and/or provider appeals, complaints and grievance policies.
• Strong analytical skills focusing on accuracy and attention to detail.
• Knowledge of clinical terminology, regulatory and accreditation requirements.
• Excellent verbal and written communication skills.
• Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees