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
Serves as a subject matter expert in complaints and appeals, providing independent coaching and guidance to ensure strict adherence to all relevant federal and state regulations. Oversees inventory management and trend analysis, proactively investigating and updating policies to resolve escalated cases from internal and external stakeholders across all product lines. Maintains compliance with all applicable regulatory agencies, Department of Public Welfare, Department of Health, and Department of Insurance. This role is critical in upholding operational integrity and supporting continuous process improvement.

Required Qualifications

• Prior experience as a Complaint and Appeal Analyst.
• Claim research knowledge or claim processing experience.
• Demonstrated ability to multi-task projects.
• Ability to work independently while researching, performing analysis, and applying resources necessary to complete a final assessment of the required and appropriate action (verbal and/or written).
• Autonomously makes decisions based upon current policies/guidelines.
• Ability to make decisions that ensure business continuity and with awareness of all possible implications and impact
• Expert knowledge of clinical terminology, and regulatory and accreditation requirements.
• Ability to coaches and support others with accuracy and ethical resolution.
• Ability to work collaboratively across the organization both internally and externally.
• Adept negotiation and analytical skills.
• 2-5 years work experience

Preferred Qualifications

• Bachelor’s degree or higher in a relevant field (e.g., healthcare administration, business, or related discipline)
• 3+ years of experience in complaints and appeals, case management, or regulatory compliance
• Demonstrated expertise in interpreting and applying federal and state healthcare regulations (such as CMS guidelines)
• Strong analytical and problem-solving skills, especially with escalated or complex cases
• Proven ability to coach, mentor, or train others in process or policy
• Experience managing inventory, trend analysis, or process improvement initiatives
• Excellent written and verbal communication skills, with a focus on clarity and professionalism
• Ability to collaborate effectively with cross-functional teams and external stakeholders
• Advanced proficiency with relevant systems or tools (e.g., case management software, reporting tools)

Education
Bachelor's Degree or equivalent work experience

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

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