Appeal and Grievance Coordinator - MUST live in OK

CVS Health•Work At Home-Oklahoma, OK

4d•$17 - $26

About The Position

The Appeal and Grievance Coordinator handles intake, investigation, and resolution of appeals, complaints, and grievances across all products. Cases may involve multiple issues and require coordination with multiple business units. The coordinator ensures timely, customer-focused responses, identifies trends and emerging issues, and reports findings and recommends potential solutions. This position must be performed by someone who lives in Oklahoma. The role includes researching incoming electronic cases, benefit and coverage language, claim processing, eligibility, and billing or payment status. The coordinator identifies appropriate resources, routes work items that do not meet the unit’s responsibilities, triages incomplete case components to subject matter experts, and coordinates all parts of the case through final communication and closure. The position also serves as a technical resource to colleagues and requires sound decisions based on current policies and guidelines, strong collaboration, accuracy, 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 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.
High school diploma or GED equivalent.

Nice To Haves

Some college preferred.
Experience researching and analyzing claim processing.

Responsibilities

Research incoming electronic appeals, complaints, and grievances to determine whether they fall within the unit’s responsibilities, and reroute inappropriate items to the correct resource.
Research the member’s Standard Plan Design or Certificate of Coverage to assess the accuracy and appropriateness of benefit or administrative denials.
Research claim-processing logic, member eligibility data, and billing or payment status before an appeal process begins.
Identify and research all components of member or provider/practitioner appeals, complaints, and grievances across products and services.
Triage incomplete case components to appropriate subject matter experts in other business units for resolution information.
Coordinate all case components through final resolution, including communication to the member or provider and case closure.
Serve as a technical resource to colleagues on appeals, complaints, grievances, and similar issues requiring additional expertise.
Identify and report trends and emerging issues and provide input on potential solutions.
Make appropriate decisions based on current policies and guidelines.
Work collaboratively and meet tight turnaround times in a fast-paced environment.