[Hiring] Grievance and Appeals- Quality Analyst @CVS Health

Role Description

Applies in-depth knowledge of subject matter and independently coaches others on matters regarding complaints and appeals, ensuring compliance with federal and/or state regulations. Ensures compliance with policies of all applicable federal and/or state government agencies, including but not limited to the Center for Medicaid and Medicare (CMS), Department of Public Welfare, Department of Health, and Department of Insurance.

• Prepares and participates in external and internal audits.
• Analyzes basic quality and completeness of the complaints and appeals documentation to ensure the accuracy, clarity, and compliance of the information provided, including supporting documentation, timelines, and required forms or processes.
• Contributes to process improvements by recommending complaint and appeal process changes, as well as new training programs to drive quality results.
• Assists in analyzing patterns, trends, and systemic issues, working with other teams to address all complaints, and escalating more complex issues and concerns to upper management for resolution.
• Compiles reports on quality metrics in order to contribute to the overall improvement of service delivery and customer satisfaction.
• Facilitates simple inquiries, providing updates, and maintaining a customer-centric approach to enhance satisfaction and promote positive experiences.
• Carries out simple tasks for compliance audits by gathering documentation, providing evidence of compliance, and assisting auditors during the review process.
• Receives and implements regular, timely feedback to ensure delivery of exceptional services and engagement, motivation, and team development.
• Acts as a liaison between the organization and relevant individuals, providing updates, explanations, and clarifications throughout the process under close supervision.

Qualifications

• 1+ years of Compliance experience
• 1+ years of External Audit Experience
• 1+ years of Grievance and Appeals Experience
• 1+ Medicare and/or Medicaid experience
• High School Diploma or GED

Requirements

• 40 hours per week
• Full time

Benefits

• 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
• 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