Analyst, Complaint & Appeals

CVS Health•Work At Home-California, CA

1d•$21 - $45

About The Position

The Integrated Appeals & Grievance Analyst is responsible for the end-to-end management of Medicare, Medicaid, Dual Eligible Special Needs Plan (D-SNP), and Integrated Plan grievances and appeals. The analyst serves as the primary case owner, ensuring timely, accurate, and compliant resolution of member and provider concerns while adhering to federal, state, contractual, and organizational requirements. This position supports a member-centric integrated model by managing appeals and grievances across Medicare and Medicaid benefit structures, coordinating investigations, issuing regulatory notices, documenting case activity, and partnering with operational, clinical, compliance, and quality teams to ensure regulatory compliance and exceptional member experience

Requirements

Knowledge of Medicare Advantage, Medicaid Managed Care, D-SNP, HIDE, FIDE, and Applicable Integrated Plan grievance and appeal requirements.
Understanding of CMS regulations, state Medicaid requirements, and fair hearing processes.
Strong analytical and investigative skills.
Ability to interpret regulations and apply them to operational casework.
Excellent written and verbal communication skills.
Strong organizational and time-management abilities.
Proficiency with case management systems, reporting tools, and Microsoft Office applications.
Ability to manage multiple priorities while maintaining accuracy and timeliness.

Nice To Haves

2-5 years of experience in Appeals, Grievances, Utilization Management, Compliance, Quality, Claims, Healthcare Operations, or related healthcare functions.
Experience working with Medicare and/or Medicaid regulations.
Experience handling regulatory casework and member correspondence preferred

Responsibilities

Receive, review, classify, investigate, and resolve integrated appeals and grievances
Independently manage standard, expedited, and highly complex cases from intake through closure.
Determine appropriate case categorization, regulatory pathway, and applicable turnaround requirements.
Ensure all cases are accurately documented and maintained in accordance with regulatory and audit requirements.
Conduct outreach to members, providers, representatives, and internal stakeholders as necessary.
Manage inventory to ensure all regulatory and departmental timeliness requirements are met