Appeal and Grievance Coordinator

CVS Health

. Intake, investigate and resolve appeals, complaints and grievances for all products .

Posted 10/19/2026full-timeRemote • United StatesJunior💰 $17 - $31 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in investigating and resolving appeals, complaints, and grievances while ensuring compliance with regulatory requirements. Proficient in analyzing claims processing and member eligibility data to provide accurate and timely responses.

Highest-signal resume keywords

Claims Platforms ExperienceRegulatory AnalysisAnalytical SkillsCommunication SkillsResearch and Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingBenefit Language ResearchPatient ManagementProduct DraftingCompliance KnowledgeGrievance PoliciesAttention to DetailClinical TerminologyAudit ExperienceProvider Relations

Soft Skills

Customer ServiceDecision MakingTime Management

Tools & Technologies

ExcelMicrosoft Word

Industry Keywords

AppealsComplaintsGrievancesRegulatory RequirementsAccreditation Requirements

About the role

Key responsibilities & impact

Intake, investigate and resolve appeals, complaints and grievances for all products
Provide timely, customer-focused responses to appeals, complaints and grievances
Research incoming electronic cases and route inappropriate work items to the correct resource
Research plan design and certification of coverage to assess benefit or administrative denials
Research claim-processing logic, member eligibility data, and billing/payment status
Identify and research all components of member and provider appeals, complaints and grievances
Triage incomplete components to subject matter experts in other business units
Coordinate all case components, including final communications and closure
Serve as a technical resource to colleagues on complex appeals, complaints and grievance issues
Identify trends and emerging issues, report findings, and provide input on potential solutions

Requirements

What you’ll need

Must live in Kentucky
1–2 years of experience including claims platforms, products and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit experience
Experience reading or researching benefit language
High school diploma or GED equivalent
Ability to meet demands of a high-paced environment with tight turnaround times
Ability to make appropriate decisions based on Aetna’s current policies/guidelines
Thorough knowledge of member and/or provider appeals, complaints and grievance policies
Strong analytical skills with accuracy and attention to detail
Knowledge of clinical terminology, regulatory and accreditation requirements
Excellent verbal and written communication skills
Computer literacy, including Excel and Microsoft Word
Some college preferred
Experience in research and analysis of claim processing preferred

Benefits

Comp & perks

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