Coordinator, Complaint & Appeals

About Cvshealth

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Job Summary

Prepares information and reports needed to address matters regarding complaints, appeals, and grievances. Carries out policies, procedures, and programs to ensure compliance with federal and/or state regulations.

Key Responsibilities

• Reviews, interprets, and processes appeals and grievances filed by patients, escalating more complex issues and concerns to management for review and follow-up.
• Performs patient and insurance report analysis and identifies any trends or issues that need to be addressed.
• Conducts reviews of decisions and case files to determine if there are any errors or anomalies in the application of law or evidence.
• Drafts and sends appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution.
• Reviews billing and coding for all current and new medical service lines for accuracy and consistency.
• Documents patient billing questions and concerns, subsequently inputting all detailed notes and records into the company database.
• Prepares educational materials, training programs, and presentations to enhance understanding of the appeals and grievances process.
• Coaches junior colleagues on best practices and standard operating procedures for handling complaints and appeals.
• Assists with the training of junior-level staff to promote the development of departmental capabilities.

Requirements

• Less than 1 year work experience
• Working knowledge of problem solving and decision making skills

Benefits & Perks

This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.