Complaint and Appeals Senior Coordinator

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

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.

What you will do

• 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.

Required Qualifications

• 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

Preferred Qualifications

• 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

Education

• High School Diploma (REQUIRED)
• Bachelor's Degree or equivalent experience (PREFERRED)

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.