Analyst, Complaints & Appeals - Work From Home
CVSHealth
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.
Applies in-depth knowledge of subject matter and independently coaches others on complaints and appeals, ensuring compliance with federal and/or state regulations. Manages control and trend inventory, and investigates, changes, or revises policy to resolve escalated cases coming from broad internal and external constituents for all products and issues. Acts independently to manage all Department of Insurance and executive complaints, and coordinates responses to all media relations. Ensures compliance with policies of all applicable federal and/or state government agencies, including but not limited to Center for Medicaid and Medicare (CMS), Department of Public Welfare, Department of Health, and Department of Insurance.
What you will do
- Creates and communicates appeal policies, procedures, and outcomes to all levels of the organization, considering potential risks and cost implications.
- Reviews and translates organizational policy into written and verbal responses for media relations, regulators, government agencies, or executive complaint line cases.
- Drafts responses to complaints based on current findings, regulations, and legislation, employing all tools associated with claims and appeals processing to mitigate risks.
- Employs expert knowledge of the healthcare industry, both internally and externally, to address complaints and appeals and resolve escalated cases.
- Educates analysts and business units on identified issues and potential risks related to claims and appeals.
- Initiates frequent communication between constituents to analyze policies, trends, and workflows, identifying areas in need of improvement.
- Manages inventories and workflows to ensure regulatory requirements are met.
- Works across all functions, segments, and teams to create, populate, and analyze reports.
For this role you will need Minimum Requirements
- Prior experience as a Complaint and Appeal Analyst.
- Claim research knowledge or claim processing experience.
- Health Insurance experience required.
- 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.
- 2+ years of experience
Education
- Bachelor's degree preferred.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$21.10 - $36.78This 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
We anticipate the application window for this opening will close on: 08/26/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.