Sr Complaints and Appeals Coordinator, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Customer Service

Contract Type:
Not provided

Salary:

18.50 - 38.82 USD / Hour

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Job Description:

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Job Responsibility:

Oversight of that that investigates and resolution of appeals scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units
Ensure timely, customer focused response to appeals
Identify trends and emerging issues and report and recommend solutions
Independently coaches others on appeals ensuring compliance with Federal and/or State regulations
Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases coming from internal and external constituents for all products
Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance and State regulators
Understand and adapt to departmental process and policies
Medicare knowledge is a plus
Fast Turn Around of inventory, collaboration with clinical team and management
Attention to detail is needed and must be able to maintain compliance turn-around times, with accurate case resolution or research
Remain a part of the solution by escalating issues that may impact compliance timeliness
Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements
Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling
Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases
Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases
Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications
Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities
Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria
Research Standard Plan Design or Certification of Coverage (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial
Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process

Requirements:

At least 2+ years in one of the following areas: claim platforms, products, and benefits
patient management
product or contract drafting
compliance and regulatory analysis
special investigations
provider relations
customer service or audit experience
2+ years of Medicare Experience
Proficient in computer use, including Excel and Electronic Health Records (EHR) systems

Nice to have:

Some Medicare and/or Medicaid knowledge
Experience in reading or researching benefit language
Ability to work in fast paced, high volume environment
Excellent verbal and written communication skills
Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics
Solution driven and can handle complex issues with accuracy
Bilingual is a plus

What we offer:

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Additional Information:

Job Posted:
August 16, 2025

Expiration:
August 29, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Sr Complaints and Appeals Coordinator