CVS Health · 7 hours ago
Senior Coordinator, Complaint & Appeals
United States
Full-time
Remote
Mid, Senior Level
$18.50/hr - $38.82/hr
2+ years expCVS Health is dedicated to building a world of health around every individual, aiming to simplify healthcare for communities. The Senior Coordinator, Complaint & Appeals is responsible for overseeing the investigation and resolution of appeals across various products, ensuring timely and customer-focused responses while coaching others on compliance with regulations.
Health CareMedicalPharmaceuticalRetailSales
Responsibilities
Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units
Ensure timely, customer focused response to appeals
Identify trends and emerging issues and report and recommend solutions
Independently coaches others on appeals ensuring compliance with Federal and/or State regulations
Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases coming from internal and external constituents for all products
Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance and State regulators
Understand and adapt to departmental process and policies
Medicare knowledge is a plus
Fast Turn Around of inventory, collaboration with clinical team and management
Attention to detail is needed and must be able to maintain compliance turn-around times, with accurate case resolution or research
Remain a part of the solution by escalating issues that may impact compliance timeliness
Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements
Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling
Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases
Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases
Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications
Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities
Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria
Research Standard Plan Design or Certification of Coverage (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial
Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process
Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities
Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria
Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial
Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services
Qualification
Required
2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
High School Diploma or GED (REQUIRED)
Preferred
Medicare and/or Medicaid knowledge
Experience in reading or researching benefit language
Ability to work in fast paced, high volume environment
Excellent verbal and written communication skills
Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics
Solution driven and can handle complex issues with accuracy
Bilingual
Benefits
Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access
Company
CVS Health
CVS Health is a health solutions company that provides an integrated healthcare services to its members.
10001+ employees
Funding
Current Stage
Public CompanyTotal Funding
$4BKey Investors
Michigan Economic Development CorporationStarboard Value
2025-08-15Post Ipo Debt· $4B
2025-07-17Grant· $1.5M
2019-11-25Post Ipo Equity
Leadership Team
David Joyner
President and Chief Executive Officer, CVS Health
Chandra McMahon
SVP & CISO
Recent News
2026-01-25
Company data provided by crunchbase