Complaint and Appeals Senior Coordinator - Remote

Overview

The Senior Ops Coordinator at CVS Health is responsible for reviewing and processing appeals filed by providers, ensuring compliance with regulatory standards, and addressing issues related to Complaint and Appeals policies.

In Short

• Review and process appeals from participating providers.
• Ensure adherence to regulatory requirements.
• Conduct internal audits and address compliance issues.
• Draft and send appeal decision letters.
• Provide support to coordinators on complex appeal issues.
• Serve as a subject matter expert for complex cases.
• Maintain performance metrics for attendance, production, and quality.
• Train and support new hires for successful onboarding.
• Meet monthly performance metrics.
• Collaborate with team members to improve processes.

Requirements

• 2+ years in appeals, compliance, or related coordination role.
• Proven success in meeting performance metrics.
• Strong knowledge of regulatory requirements.
• Excellent written and verbal communication skills.
• Ability to mentor peers on complex issues.
• Proficiency with relevant software and case management tools.
• Medicare and claims experience preferred.
• Experience in researching benefit language.
• High School Diploma required; Bachelor's degree preferred.
• Ability to analyze claim processing.

Benefits

• Competitive wages and comprehensive benefits.
• Affordable medical plan options.
• 401(k) plan with matching contributions.
• No-cost wellness programs for all colleagues.
• Flexible work schedules and paid time off.
• Tuition assistance and family leave options.
• Employee stock purchase plan.
• Confidential counseling and financial coaching services.
• Retiree medical access and dependent care resources.
• Commitment to employee wellness and satisfaction.