Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

A Brief Overview
Applies in-depth knowledge of subject matter and independently coaches others on matters regarding complaints and appeals, ensuring compliance with federal and/or state regulations. Ensures compliance with policies of all applicable federal and/or state government agencies, including but not limited to the Center for Medicaid and Medicare (CMS), Department of Public Welfare, Department of Health, and Department of Insurance.

What you will do

Coordinates reviews and evaluations for complaints and appeals received by the organization including denied claims, coverage issues, medical necessity, service quality, or other concerns expressed by patients, providers, or other stakeholders.Analyzes basic quality and completeness of the complaints and appeals documentation to ensure the accuracy, clarity, and compliance of the information provided, including supporting documentation, timelines, and required forms or processes.Contributes to process improvements by recommending complaint and appeal process changes, as well as new training programs to drive quality results.Assists in analyzing patterns, trends, and systemic issues, working with other teams to address all complaints, and escalating more complex issues and concerns to upper management for resolution.Compiles reports on quality metrics in order to contribute to the overall improvement of service delivery and customer satisfaction.Facilitates simple inquiries, providing updates, and maintaining a customer-centric approach to enhance satisfaction and promote positive experiences.Carries out simple tasks for compliance audits by gathering documentation, providing evidence of compliance, and assisting auditors during the review process.Receives and implements regular, timely feedback to ensure delivery of exceptional services and engagement, motivation, and team development.Acts as a liaison between the organization and relevant individuals, providing updates, explanations, and clarifications throughout the process under close supervision.

Required Qualifications
Compliance experience

Audit Experience

Grievance and Appeals Experience

Education
High School Diploma or GED

Pay Range

The typical pay range for this role is:

$21.10 - $36.78

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.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 01/31/2025

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