Sr Coordinator, Complaint and Appeals Operations, CVS Health

CVS Health

Location:
United States, Work at Home, California

Category:
Customer Service

Contract Type:
Employment contract

Salary:

18.50 - 42.35 USD / Hour

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Job Description:

Responsible for managing to resolution Fast Track Appeal scenarios for Medicare 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. Act as 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 resolve Fast Track Appeals as appropriate
Identify and reroute inappropriate work items that do not meet appeal criteria
Identify trends in misrouted work
Assemble all data used in making denial determinations
Act as subject matter expert regarding unit workflows
fiduciary responsibility and appeals processes and procedures
Research standard plan design, certification of coverage and potential contractual deviations to determine accuracy and appropriateness of a benefit/administrative denial
Review clinical determinations and understand rationale for decisions
Research claim processing logic and verify accuracy of claim payment
member eligibility data and billing/payment status
Serve as point person for newer staff
Educate team mates and other areas on components within member or provider/practitioner complaints/appeals
Coordinate efforts internally and across departments to resolve claims research
SPD/COC interpretation
letter content
state or federal regulatory language
triage complaint/appeal issues and situations requiring higher-level expertise
Deliver internal quality reviews
provide support for third party audits, customer meetings, regulatory meetings and consultant meetings
Respond to Executive complaints and appeals
Follow up to assure Fast Track appeal is handled within established timeframe to meet company and regulatory requirements
Act as single point of contact for Fast Track appeals on behalf of members or providers

Requirements:

Knowledge of Fast Track Appeals and includes CMS Guidelines for Fast Track Appeals
MS Word
MS EXCEL
MHK
QuickBase applications
Avaya System
GPS

Nice to have:

2-3 years' experience that includes both Medicare platforms
products and benefits; patient management; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
experience in research and analysis of utilization management systems
Fluent in Spanish, both oral and written

What we offer:

Affordable medical plan options
401(k) plan (including matching company contributions)
employee stock purchase plan
no-cost programs including wellness screenings
tobacco cessation and 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 18, 2025

Expiration:
November 28, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Sr Coordinator, Complaint and Appeals Operations