Coordinator, Complaint & Appeals Operations, CVS Health

CVS Health

Location:
United States, Work at Home

Category:
Customer Service

Contract Type:
Employment contract

Salary:

17.00 - 28.46 USD / Hour

Save Job

Apply Position

Job Description:

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. 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.

Job Responsibility:

Reviews and processes appeals and grievances filed by patients
Assists with adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues
Conducts reviews of decisions and case files to determine if there are errors in the application of law or evidence
Drafts and sends appeal decision letters
Identifies key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process
Documents patient billing questions and concerns
Prepares educational materials, training programs, or presentations to enhance understanding of the appeals and grievances process
Coaches junior colleagues on best practices and standard operating procedures
Assists with the training of junior-level staff to promote the development of departmental capabilities
Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit
Research Standard Plan Design or Certification of Coverage relevant to the member
Research claim processing logic to verify accuracy of claim payment
Identify and research all components within member or provider/practitioner appeals, complaints and grievance

Requirements:

Experience in reading or researching benefit language
1-2 years experience that includes but is not limited to claim platforms, products, and benefits
patient management
product or contract drafting
compliance and regulatory analysis
special investigations
provider relations
customer service or audit experience
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
Ability to meet demands of a high paced environment with tight turnaround times

Nice to have:

Experience in research and analysis of claim processing
Some college preferred

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
October 22, 2025

Expiration:
October 31, 2025

Employment Type:

Fulltime

Work Type:

Remote work

View All Jobs In This Company

Job Link Share:

Coordinator, Complaint & Appeals Operations