Coordinator, Complaint & Appeals

CVS Health

1d•Remote

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. This position can be anywhere in the United States.

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

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 is a plus

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.