Sr Appeal and Grievance Coordinator

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

Coordinate effective resolution of member or provider/practitioner appeals.

Responsible for managing to resolution of appeals, complaints and grievances scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. May have contact with outside plan sponsors or regulators.

-Research and resolve incoming electronic appeals, complaints and grievances as appropriate as a “single-point-of-contact” based on type of case.

-Can identify and reroute inappropriate work items that do not meet appeal, complaint and grievance criteria as well as identify trends in misrouted work.
-Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, appeals, complaints and grievances processes and procedures.
-Can review a clinical determination and understand rationale for decision.
-Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process.

-Serves as point person for newer staff in answering questions associated with claims/customer service systems and products.
-Educates team mates as well as other areas on all components within member or provider/practitioner appeals, complaints and grievances for all products and services.
-Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of appeals, complaints and grievances, and similar situations requiring a higher level of expertise.
-Identifies trends and emerging issues and reports on and gives input on potential solutions.
-Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required.
-Understands and can respond to ERT/SMRT/DOI/BBB appeals, complaints and grievances

Required Qualifications

Excellent written and oral communication skills.
Ability to work cross organizationally.

Strong analytical skills focusing on accuracy and attention to detail.

Preferred Qualifications

Experience in reading or researching benefit language.
Experience in research and analysis of claim processing a plus.
Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Ability to maintain accuracy and production standards.

Education Associate's degree or equivalent work experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$18.50 - $38.82

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 03/31/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.