Coordinator, Complaint & Appeals, CVS Health

CVS Health

Location:
United States

Category:
Customer Service

Contract Type:
Employment contract

Salary:

17.00 - 31.30 USD / Hour

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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 managing to resolution complaint/appeal scenarios for all products, which may contain multiple issues and may require coordination of responses from multiple business units.

Job Responsibility:

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
Reviews and processes appeals and grievances filed by patients
Assists with adherence to regulatory requirements
Conducts internal audits
Addresses identified compliance issues with the Complaint and Appeals policies and procedures
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
Manages to resolution complaint/appeal scenarios for all products
Coordinates responses from multiple business units
Ensure timely, customer focused response to complaints/appeals
Identify trends and emerging issues and report and recommend solutions

Requirements:

1 year experience that includes both HMO and Traditional claim platforms, products, and benefits
patient management experience
product, compliance and regulatory analysis experience
special investigations experience
provider relations experience
customer service experience
audit experience
High School or Equivalent education

Nice to have:

Medicare experience
Claims experience
Experience in reading or researching benefit language in Summary Plan Description (SPDs) or Certificate of Coverage (COCs)
Experience in research and analysis of claim processing

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
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:
November 05, 2025

Expiration:
November 05, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Coordinator, Complaint & Appeals