Full-Time

Appeal and Grievance Coordinator

Confirmed live in the last 24 hours

CVS Health

CVS Health

10,001+ employees

Comprehensive pharmacy and healthcare services

Healthcare
Consumer Goods

Compensation Overview

$17 - $25.65Hourly

Junior

Company Historically Provides H1B Sponsorship

Remote in USA

Must live in Kentucky.

Category
Legal
Risk & Compliance
Legal & Compliance
Required Skills
Word/Pages/Docs
Customer Service
Excel/Numbers/Sheets
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.
Responsibilities
  • Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products.
  • Ensure timely, customer focused response to appeals, complaints and grievance.
  • Identify trends and emerging issues and report and recommend solutions.
  • 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.
Desired Qualifications
  • Experience in research and analysis of claim processing a plus.

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines retail pharmacy services with a pharmacy benefits manager and senior care services, making it a comprehensive solution for health management. The company's goal is to enhance access to quality care and support people in achieving better health.

Company Stage

Debt Financing

Total Funding

N/A

Headquarters

Woonsocket, Rhode Island

Founded

1963

Simplify Jobs

Simplify's Take

What believers are saying

  • Expansion of telehealth services allows CVS to reach more patients remotely.
  • Increased consumer interest in wellness boosts demand for CVS's health-related products.
  • The trend towards value-based care aligns with CVS's integrated healthcare approach.

What critics are saying

  • Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.
  • The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.
  • The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

What makes CVS Health unique

  • CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.
  • The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.
  • CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

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Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays