CVS Health is looking for a Complaint and Appeals Senior Coordinator to ensure the integrity of our appeals process. In this role, you will review appeals from participating providers, uphold regulatory standards, and act as a key resource for resolving complex cases.
What You'll Do
- 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.
What We're Looking For
- 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.
Nice to Have
- 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.
Benefits & Compensation
- Compensation: $18.50 - $31.72 per hour.
- Affordable medical plan options.
- 401(k) plan including matching company contributions.
- Employee stock purchase plan.
- No-cost wellness screenings, tobacco cessation and weight management programs.
- No-cost confidential counseling and financial coaching.
- Paid time off.
- Flexible work schedules.
- Family leave.
- Dependent care resources.
- Colleague assistance programs.
- Tuition assistance.
- Retiree medical access.
Work Mode
This is a full time position.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
