Appeals, Complaints and Grievances Specialist

We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.

At CVS Health, you'll be surrounded by colleagues who care deeply, innovate with purpose, hold themselves accountable and prioritize safety and quality in everything they do.

Job Summary

The Appeals, Complaints and Grievances Specialist is responsible for the intake, investigation, and resolution of appeals, complaints, and grievances scenarios for all products.

Key Responsibilities

• Research and investigate appeals, complaints, and grievances to identify correct resources and reroute inappropriate work items
• Analyze Standard Plan Design or Certification of Coverage to determine accuracy and appropriateness of benefit or administrative denial
• Verify claim processing logic to ensure accuracy of claim payment, member eligibility data, and billing/payment status
• Identify and research all components within member or provider/practitioner appeals, complaints, and grievance for all products and services
• Coordinate with subject matter experts to resolve incomplete components of appeals, complaints, and grievance
• Serve as a technical resource to colleagues regarding appeals, complaints, and grievance issues
• Identify trends and emerging issues and report on and give input on potential solutions

Requirements

• Ability to meet demands of a high-paced environment with tight turnaround times
• Ability to make appropriate decisions based on current policies and 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

Qualifications

• Experience in reading or researching benefit language
• 1-2 years of experience in claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit experience

Preferred Qualifications

• Experience in research and analysis of claim processing

Education

• Some college preferred
• High School or GED equivalent

Benefits

• Comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources