As the Appeal and Grievance Coordinator at CVS Health, you will be responsible for intake, investigation, and resolution of appeals, complaints, and grievances scenarios for all products. You will ensure timely, customer-focused responses to appeals, complaints, and grievances, and identify trends and emerging issues to report and recommend solutions.
Requirements
- Research incoming electronic appeals, complaints, and grievance to identify if appropriate for unit based upon published business responsibilities
- 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
Benefits
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility
