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

Role Description

Responsible for oversight of that investigates and resolution of appeals scenarios for all products, which may contain multiple issues and may require coordination of responses from multiple business units. Ensure timely, customer-focused response to appeals. Identify trends and emerging issues and report and recommend solutions. Independently coaches others on appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, adapt to changes or revise policy to resolve the most escalated cases coming from internal and external constituents for all products. Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance, and State regulators. Understand and adapt to departmental process and policies. Medicare knowledge is a plus. Fast turnaround of inventory, collaboration with clinical team and management. Attention to detail is needed and must be able to maintain compliance turnaround times, with accurate case resolution or research. Remain a part of the solution by escalating issues that may impact compliance timeliness. Additional duties as assigned which will include carrying a modified case load including but not limited to:

• Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements.
• Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turnaround time for appeals, complaints, and grievances handling.
• Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases.
• Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.
• Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.
• Research incoming electronic appeals, complaints, and grievances to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints, and grievance criteria.
• Research Standard Plan Design or Certification of Coverage (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
• Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
• Identify and research all components within member or provider/practitioner appeals, complaints, and grievances for all products and services.

Qualifications

• At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.

Preferred Qualifications

• Some Medicare and/or Medicaid knowledge.
• Experience in reading or researching benefit language.
• Ability to work in fast-paced, high-volume environment.
• Excellent verbal and written communication skills.
• Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics.
• Solution driven and can handle complex issues with accuracy.

Education

• High School or GED.

Anticipated Weekly Hours

• 40

Time Type

• Full time

Pay Range

The typical pay range for this role is: $18.50 - $38.82. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography, and other relevant factors.

Benefits

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include:

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

Application Information

We anticipate the application window for this opening will close on: 07/30/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.