[Hiring] Senior Analyst, Complaints & Appeals @CVS Health

Role Description

The Sr. Analyst, Complaints & Appeals is responsible for performing quality reviews and audits of appeals, complaints, and grievance resolutions and root cause analysis to determine if cases were handled in accordance with CMS, state and/or federal guidelines and regulations and ensure member experience. Prepares information on audit findings, and provides insights on data, training, process, and program updates for either Medicare or Commercial Line of Business. The role develops reports, dashboards, and key performance indicators to support business decision-making and regulatory compliance. The analyst collaborates with cross-functional stakeholders to investigate issues, conduct root cause analyses, implement corrective actions, and improve operational effectiveness. The position requires strong analytical, problem-solving, communication, stakeholder management, and decision-making skills and supports multiple projects within a fast-paced healthcare environment.

Qualifications

• 3-5 years of experience in healthcare operations, complaints and appeals, analytics, quality, compliance, governance, risk management, or related functions.
• Strong analytical, problem-solving, and decision-making skills.
• Experience conducting trend analysis, root cause analysis, operational reviews, and process improvement initiatives.
• Experience developing reports, dashboards, and executive-level presentations.
• Strong written and verbal communication skills.
• Demonstrated ability to collaborate across multiple business functions and influence stakeholders.
• Advanced proficiency with Microsoft Excel, Microsoft PowerPoint, reporting tools, and data analysis methodologies.

Requirements

• Medicare Advantage, Part D, Grievance, CTM, Commercial Appeals, Provider Appeals, Claim operations, Grievance experience or Appeals experience.
• Knowledge of CMS regulations and Medicare complaint and appeal requirements.
• Knowledge of quality management, operational governance, and remediation tracking practices.
• Experience supporting governance, remediation tracking, and operational improvement initiatives.
• Knowledge of healthcare regulations, quality programs, and complaint and appeal workflows.
• Experience with automation initiatives, reporting optimization, or business intelligence solutions.
• Experience supporting executive-level reporting and operational performance reviews.

Benefits

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