Complaint and Appeals Senior Coordinator

CVS Health • Carapichaima, TN

23h • $19 - $32

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Senior Ops Coordinator reviews and processes appeals filed by participating providers, ensures adherence to regulatory requirements, and addresses compliance issues related to Complaint and Appeals policies. This role conducts internal audits, drafts appeal decision letters, and serves as a subject matter expert (SME) for complex cases.

Requirements

• 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
• High School Diploma (REQUIRED)

Nice To Haves

• 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
• Bachelor's Degree or equivalent experience (PREFERRED)

Responsibilities

• Review and process appeals filed by participating providers.
• Assist with adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
• Drafts and sends appeal decision letters.
• Provide peer support to coordinators when handling complex appeal issues.
• Serves 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.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED