Sr Coordinator, Complaint and Appeals Operations

CVS Health Job Opportunity

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 schedule for this role is Sunday - Thursday 12 - 9 Eastern Time. Department is open 7 days a week, 365 days a year from 8am-8pm. We work weekends, and holidays. Responsible for managing to resolution Fast Track Appeal scenarios for Medicare products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. Act as a subject matter expert by providing training, coaching, or responding to complex issues. May have contact with outside plan sponsors or regulators. Research and resolves Fast Track Appeals as appropriate. Can identify and reroute inappropriate work items that do not meet 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. Serves as point person for newer staff in answering questions associated with claims / customer service systems and products. Educates team mates as well as other areas on all components within member or provider / practitioner complaints / appeals for all products and services. 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. Follow up to assure Fast Track appeal is handled within established timeframe to meet company and regulatory requirements. Act as single point of contact for Fast Track appeals on behalf of members or providers, as assigned.

Required Qualifications

Knowledge of Fast Track Appeals and includes CMS Guidelines for Fast Track Appeals, MS Word, MS EXCEL, MHK, QuickBase applications, Avaya System, GPS

Preferred Qualifications

2-3 years' experience that includes both Medicare platforms, products, and benefits; patient management; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience. Experience in research and analysis of utilization management systems. Fluent in Spanish, both oral and written

Education

HS Diploma, Associate's degree or equivalent experience

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is : $18.50 - $42.35. 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.

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.

We anticipate the application window for this opening will close on : 11 / 28 / 2025. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex / gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.