[Hiring] Senior Coordinator, Complaint and Appeals @CVS Health

Role Description

Prepares, researches, and evaluates information necessary to resolve member complaints, appeals, and grievances. Reviews case documentation, analyzes benefit and policy information, and ensures accurate, timely, and compliant case resolution in accordance with established procedures and regulatory requirements.

The Complaints & Appeals Analyst is responsible for reviewing, investigating, and resolving member complaints, appeals, and grievances. This role requires strong analytical and problem-solving skills to evaluate case information, research complex issues, and communicate clear and accurate determinations. The analyst works collaboratively with internal business partners to ensure cases are resolved accurately, timely, and in accordance with applicable policies and procedures.

• Reviews and investigates member complaints, appeals, and grievances in accordance with established policies and procedures.
• Analyzes case information, supporting documentation, and benefit information to determine appropriate case outcomes.
• Prepares accurate and timely written correspondence related to complaint and appeal determinations.
• Ensures cases are processed within established quality, productivity, and turnaround time standards.
• Researches and resolves complex issues by collaborating with internal business partners and applicable stakeholders.
• Maintains accurate and complete case documentation in applicable systems.
• Identifies potential trends or process concerns and escalates issues as appropriate.
• Participates in departmental projects, training, and process improvement initiatives.
• Supports compliance with federal and state regulations and internal policies governing complaint and appeal activities.

Qualifications

• 5+ years of work experience with Medicaid Complaint & Appeals
• Strong analytical, problem-solving, and decision-making skills.
• Excellent written and verbal communication skills.
• Ability to manage multiple priorities and adhere to established deadlines.
• Proficiency in Microsoft Office applications.

Requirements

• Experience in healthcare, insurance, claims, customer service, complaints and appeals, or related operations.
• Experience researching and resolving complex customer or member issues.
• Knowledge of health plan benefits, claims, and appeals processes preferred.

Education

• High school diploma or equivalent required.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.