Senior Analyst, Complaints & Appeals (Medicare and/or Commercial) - Remote

CVS Health•Work At Home-Connecticut, CT

2d•$46,988 - $112,200•Remote

About The Position

The Senior Analyst, Complaints & Appeals performs quality reviews and audits of appeals, complaints, and grievance resolutions, including root cause analysis, to assess compliance with CMS, state, and federal requirements and support a consistent member experience. The role prepares audit findings and insights on data, training, processes, and program updates for a Medicare or Commercial line of business. It develops reports, dashboards, and key performance indicators to inform business decisions and support regulatory compliance. The analyst collaborates with cross-functional stakeholders to investigate issues, identify trends and operational risks, plan and track corrective actions, and improve operational effectiveness. The position supports multiple projects in a fast-paced healthcare environment and requires strong analytical, problem-solving, communication, stakeholder management, and decision-making skills.

Requirements

3–5 years of experience in healthcare operations, complaints and appeals, analytics, quality, compliance, governance, risk management, or related functions.
Strong analytical, problem-solving, and decision-making skills.
Experience conducting trend analysis, root cause analysis, operational reviews, and process improvement initiatives.
Experience developing reports, dashboards, and executive-level presentations.
Strong written and verbal communication skills.
Demonstrated ability to collaborate across multiple business functions and influence stakeholders.
Advanced proficiency with Microsoft Excel, Microsoft PowerPoint, reporting tools, and data analysis methodologies.
Bachelor’s degree preferred or an equivalent combination of education, professional experience, and relevant healthcare operational expertise.

Nice To Haves

Experience with Medicare Advantage, Part D, Grievance, CTM, Commercial Appeals, Provider Appeals, claims operations, or appeals.
Knowledge of CMS regulations and Medicare complaint and appeal requirements.
Knowledge of quality management, operational governance, and remediation tracking practices.
Experience supporting governance, remediation tracking, and operational improvement initiatives.
Knowledge of healthcare regulations, quality programs, and complaint and appeal workflows.
Experience with automation initiatives, reporting optimization, or business intelligence solutions.
Experience supporting executive-level reporting and operational performance reviews.

Responsibilities

Perform quality reviews and analyze grievance and appeal resolutions for compliance with CMS, state, and federal regulations and consistency of member experience.
Conduct end-to-end quality reviews and analysis, identifying opportunities to improve outcomes and operational performance.
Conduct root cause analysis, identify trends, analyze operational data, and develop recommendations to reduce complaint, grievance, and appeal drivers.
Analyze complaint, appeal, overturn, and operational performance data for trends affecting customer experience, claims outcomes, and business performance.
Lead root cause analysis and governance activities for complaint and appeal issues, including issue identification and validation, corrective action planning, remediation tracking, and development of findings and recommendations.
Develop and maintain process documentation, job aids, governance materials, and operational guidance; serve as a subject matter expert and contribute analytical support, knowledge sharing, training, and continuous improvement.
Prepare reports, dashboards, presentations, and leadership summaries covering audit findings, operational risks, trend analysis, and process improvement opportunities.
Identify process gaps, operational defects, and compliance risks and recommend improvements to quality performance, administrative efficiency, and customer experience.
Partner with Operations, Compliance, Clinical, Claims, Product, and Technology teams to improve resolution quality, operational processes, work instructions, and member experience.
Develop actionable insights from appeal trends and root cause analyses to support leadership decisions, governance reviews, and continuous improvement.