[Hiring] Coordinator, Complaint & Appeals @CVS Health

Role Description

The Senior Ops Coordinator reviews and processes appeals filed by participating providers, ensures adherence to regulatory requirements, and addresses compliance issues related to Complaint and Appeals policies. This role conducts internal audits, drafts appeal decision letters, and serves as a subject matter expert (SME) for complex cases. This position can be anywhere in the United States.

• Review and process appeals filed by participating providers.
• Assist with adherence to regulatory requirements, conduct internal audits, and address any identified compliance issues with the Complaint and Appeals policies and procedures.
• Draft and send appeal decision letters.
• Provide peer support to coordinators when handling complex appeal issues.
• Serve as SME for handling complex cases such as CA IPA or SIU cases.
• Maintain successful performance for meeting monthly metrics for attendance, production, and quality.
• Provide training and ongoing support to new hires to ensure successful onboarding and integration into team processes.

Qualifications

• 2+ years in appeals, compliance, or a related coordination role.
• Proven success in meeting monthly metrics for attendance, production, and quality.
• Strong knowledge of regulatory requirements and compliance standards.
• Excellent written and verbal communication skills.
• Ability to support and mentor peers on complex issues.
• Proficiency with relevant software and case management tools.

Requirements

• Medicare experience.
• Claims experience.
• Experience in reading or researching benefit language in Summary Plan Description (SPDs) or Certificate of Coverage (COCs).
• Experience in research and analysis of claim processing is a plus.

Education

• Bachelor's degree or equivalent experience.

Benefits

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources, based on eligibility.