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 passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary/Mission
Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. 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.
Background Experience Required
-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.
Background Experience Preferred
-Experience in research and analysis of claim processing a plus.
Education and Certification Requirements
-Some college preferred.
-High School or GED equivalent.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$17.00 - $25.65This 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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Skills Required
- Experience reading or researching benefit language.
- 1-2 years experience with claim platforms, products, and benefits; patient management; contract or product drafting; compliance/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 attention to detail and accuracy.
- Excellent verbal and written communication skills.
- Computer literacy to navigate internal/external systems, including Excel and Microsoft Word.
- Ability to meet demands of a high-paced environment with tight turnaround times.
- Ability to make decisions based on company policies/guidelines and collaborate across teams.
- Some college (preferred).
- Experience in research and analysis of claim processing (preferred).
- High School diploma or GED equivalent.
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
