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Senior Coordinator Complaint Appeals

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States , Work at Home

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Category:
Customer Service

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Contract Type:
Not provided

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Salary:

18.50 - 35.29 USD / Hour
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Job Description:

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Job Responsibility:

  • Responsible for managing to resolution appeal scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units
  • Research and resolves incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal
  • Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work
  • Assemble all data used in making denial determinations and can 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 to determine the accuracy and appropriateness of a benefit/administrative denial
  • Can review a clinical determination and understand rationale for decision
  • Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process
  • Serves as point person for newer staff in answering questions associated with claims/customer service systems and products
  • Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise
  • Identifies trends and emerging issues and reports on and gives input on potential solutions
  • Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required
  • Understands and can respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned

Requirements:

  • 1 year experience in reading or researching benefit language in SPDs or COCs
  • Demonstrated ability to handle multiple assignments competently, accurately and efficiently
  • Excellent verbal and written communication skills
  • Computer navigation ability and ability to multitask
  • Excellent customer service skills
  • Strong Leadership skills
  • Experience documenting workflows and reengineering efforts

Nice to have:

  • 1 year of experience in research and analysis of claim processing
  • 1-2 years Medicare part C Appeals experience
  • Project management skills are preferred
  • Strong knowledge of all case types including all specialty case types
What we offer:
  • Affordable medical plan options
  • 401(k) plan (including matching company contributions)
  • Employee stock purchase plan
  • No-cost programs for all colleagues including 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:
March 24, 2026

Expiration:
March 24, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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