Senior Coordinator Complaint Appeals Operations, CVS Health

CVS Health

Location:
United States, Austin

Category:
Customer Service

Contract Type:
Employment contract

Salary:

18.50 - 35.29 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:

Research and resolves incoming electronic appeals as appropriate as a single-point-of-contact based on type of appeal
Identify and reroute inappropriate work items that do not meet complaint/appeal criteria
Identify trends in misrouted work
Assemble all data used in making denial determinations
Act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures
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 to verify accuracy of claim payment
Coordinate efforts both internally and across departments to successfully resolve claims research
Identify trends and emerging issues and report on potential solutions
Deliver internal quality reviews
Provide support in third party audits, customer meetings, regulatory meetings and consultant meetings
Respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals

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

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 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 27, 2025

Expiration:
December 03, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Coordinator Complaint Appeals Operations