Complaint & Appeal Coordinator
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Job Description
CVS Health coordinator investigating and resolving member and provider appeals, complaints, and grievances. Researching benefits, claims, eligibility, and regulatory requirements for timely resolutions.
Responsibilities:
- Intake, investigate, and resolve appeals, complaints, and grievances across all products
- Research incoming electronic cases and route inappropriate work items to the correct resource
- Research plan design or coverage certification to assess benefit or administrative denials
- Research claim-processing logic, claim payments, member eligibility data, and billing/payment status
- Identify and research all components of member or provider appeals, complaints, and grievances
- Triage incomplete components to subject matter experts in other business units
- Coordinate case components, final communications, resolution, and closure
- Serve as a technical resource to colleagues on appeals, complaints, and grievance issues
- Identify trends and emerging issues, report findings, and provide input on potential solutions
Requirements:
- Must reside in Ohio
- Experience in reading or researching benefit language
- 1–2 years experience including claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit experience
- Thorough knowledge of member and/or provider appeals, complaints and grievance policies
- Knowledge of clinical terminology, regulatory and accreditation requirements
- Strong analytical skills with accuracy and attention to detail
- Excellent verbal and written communication skills
- Computer literacy, including Excel and Microsoft Word
- Ability to meet demands of a high-paced environment with tight turnaround times
- Ability to make appropriate decisions based on current policies/guidelines
- Collaborative working relationships
- High School or GED equivalent
Benefits:
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility
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