CVS Health · 20 hours ago
Senior Coordinator, Complaint & Appeals - Remote
United States
Full-time
Remote
Mid, Senior Level
$18.50/hr - $35.29/hr
1+ years expCVS Health is committed to building a world of health around every individual, offering a connected and compassionate health experience. The Senior Coordinator, Complaint & Appeals will manage complex appeal scenarios, ensuring resolution through coordination with various business units and acting as a subject matter expert in the appeals process.
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Responsibilities
Research and resolves incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal
Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work
Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures
Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial
Can review a clinical determination and understand rationale for decision
Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process
Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise
Identifies trends and emerging issues and reports on and gives input on potential solutions
Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required
Understands and can respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned
Qualification
Required
1-2 years Medicare part C Appeals experience
Experience in reading or researching benefit language in SPDs or COCs
Experience in research and analysis of claim processing a plus
Demonstrated ability to handle multiple assignments competently, accurately and efficiently
Excellent verbal and written communication skills
Excellent customer service skills
Experience documenting workflows and reengineering efforts
Preferred
Strong knowledge of all case types including all specialty case types
Project management skills are preferred
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.
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
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