Complaint Resolution Specialist

6 days ago


Trenton, New Jersey, United States CVS Health Full time
About Us

CVS Health is a dynamic organization dedicated to delivering enhanced human-centric healthcare solutions. Our purpose is to bring our heart to every moment of your health, making us an ideal employer for those passionate about transforming the healthcare landscape.

Job Overview

We are seeking a highly skilled Complaint Resolution Specialist - Patient Advocacy to join our team. This role plays a critical part in ensuring timely and customer-focused responses to appeals, complaints, and grievances scenarios for all products. The successful candidate will identify trends and emerging issues, report, and recommend solutions to enhance our services.

Responsibilities
  • Intake and Investigation: Research incoming electronic appeals, complaints, and grievances to determine their appropriateness for resolution by our team. Identify correct resources and reroute work items that do not meet criteria.
  • Accuracy and Verification: Research Standard Plan Design or Certification of Coverage relevant to members to ensure accuracy and appropriateness of benefits/administrative denials. Verify claim processing logic for accurate payment, member eligibility data, billing/payment status before initiating the appeal process.
  • Triage and Coordination: Identify and research all components within member or provider/practitioner appeals, complaints, and grievances for all products and services. Triage incomplete components to subject matter experts within other business units for resolution response content to be included in final resolution responses.
  • Communication and Collaboration: Coordinate all components of appeals, complaints, and grievances, including final communication to members/providers for final resolution and closure. Serve as a technical resource to colleagues regarding appeals, complaints, and grievance issues, providing expert guidance.
  • Analysis and Reporting: Identify trends and emerging issues, reporting on potential solutions to improve our services. Utilize strong analytical skills focusing on accuracy and attention to detail, with thorough knowledge of member and/or provider appeals, complaints, and grievance policies.
Requirements
  • Experience: 1-2 years in reading or researching benefit language, claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service, or audit experience.
  • Education: Some college preferred; High School or GED equivalent required.
What We Offer

In addition to competitive compensation and comprehensive benefits, we offer a fully-paid term life insurance plan, short-term and long-term disability benefits, Paid Time Off (PTO), paid holidays, sick time, and more. Our well-being programs, education assistance, and free development courses support your growth and success. With CVS Health, you'll enjoy a range of benefits that cater to your physical, emotional, and financial well-being.

The estimated salary for this role is $23.50-$40.25 per hour, based on location and experience.



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