Senior Coordinator Complaint Appeals Operations, CVS Health

CVS Health

Location:
United States, Work at Home

Category:
Customer Service

Contract Type:
Employment contract

Salary:

18.50 - 38.82 USD / Hour

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Job Description:

Responsible for managing to resolution appeal scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. Develop into a subject matter expert by providing training, coaching, or responding to complex issues. May have contact with outside plan sponsors or regulators.

Job Responsibility:

Responsible for managing to resolution appeal scenarios for all products
Develop into a subject matter expert by providing training, coaching, or responding to complex issues
Research and resolves incoming electronic appeals as appropriate
Identify and reroute inappropriate work items that do not meet complaint/appeal criteria
Assemble all data used in making denial determinations
Research standard plan design, certification of coverage and potential contractual deviations
Review clinical determinations and understand rationale for decision
Research claim processing logic and various systems
Coordinates efforts both internally and across departments
Identifies trends and emerging issues
Delivers internal quality reviews
Understands and can respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints

Requirements:

1-2 years Medicare part C Appeals experience
Experience in reading or researching benefit language in SPDs or COCs
Experience in research and analysis of claim processing a plus
Demonstrated ability to handle multiple assignments competently, accurately and efficiently
Excellent verbal and written communication skills
Excellent customer service skills
Experience documenting workflows and reengineering efforts
High School Diploma

Nice to have:

Strong knowledge of all case types including all specialty case types
Project management skills are 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:
November 03, 2025

Expiration:
November 28, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Coordinator Complaint Appeals Operations