Complaint Appeals Analyst

Job DescriptionResearch incoming electronic appeal requests to identify if appropriate for unit based on published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals criteria.-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 provider/practitioner appeals for all products and services.-Ability to meet demands of a high paced environment with tight turnaround times.-Ability to make appropriate decisions based upon Aetna's current policies and guidelines.-Collaborative working relationships.-Thorough knowledge of provider appeals policies-Strong analytical skills focusing on accuracy and attention to detail.-Excellent verbal and written communications skills.-Computer literacy in order to navigate through internal/external computer systems , including Excel and Microsoft Word.-May also include mailroom duties, will need to go in office to perform duties.-will make calls to providers when necessary, will review incoming faxes, emails and voicemails.Pay RangeThe typical pay range for this role is:Minimum: 17.00Maximum: 27.16Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required QualificationsExperience in reading or researching benefit language.-1-2 years' experience that includes but is not limited to claim platforms, products, and benefits; patient management; compliance and regulatory analysis; customer service or audit experience.Must have QNXT and DAG (Casetrakker) experiencePreferred Qualifications :-Experience in research and analysis of claim processing a plus Education :High School diploma or GEDPreferred QualificationsExperience in research and analysis of claim processing a plusEducationHigh School or GED equivalent.Business OverviewBring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Created: 2025-11-15