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

CVS Health•Work At Home-New Jersey, NJ

4d•$17 - $31

About The Position

The Appeal and Grievance Coordinator is responsible for intake, investigation, and resolution of appeals, complaints, and grievances across 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 on them while recommending potential solutions. The position requires living in Kentucky, Oklahoma, or Ohio.

Requirements

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.
Ability to work in a fast-paced environment with tight turnaround times.
Ability to make appropriate decisions based on current Aetna policies and guidelines.
Collaborative working relationships.
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 and ability to navigate internal and external systems, including Excel and Microsoft Word.
High school diploma or GED equivalent.

Nice To Haves

Experience in research and analysis of claim processing.
Some college.

Responsibilities

Review incoming electronic appeals, complaints, and grievances to determine whether they belong to the unit based on published business responsibilities, and route inappropriate items to the correct resource.
Review 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, 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 components to appropriate subject matter experts in other business units and obtain content for the final resolution response.
Coordinate all components of appeals, complaints, and grievances, including final communication to members or providers and case closure.
Serve as a technical resource to colleagues on appeals, complaints, grievances, and similar issues requiring greater expertise.
Identify and report trends and emerging issues and provide input on potential solutions.