Senior Coordinator, Complaint & Appeals - Remote

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

A Brief Overview
This position is for a Dental Senior. Prepares information and reports needed to address matters regarding complaints, appeals, and grievances. Carries out policies, procedures, and programs to ensure compliance with federal and/or state regulations.

Schedule: Wednesday-Sunday
What you will do

• Conducts team reviews, interpretations, and appeals filed by patients, escalating more complex issues and concerns to management for review and follow-up.
• Ensures adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
• Facilitates in-depth reviews of decisions and case files to determine if there are errors or anomalies in the application of law or evidence.
• Oversees the drafting and progression of appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution.
• Monitors key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process.
• Ensures all front-line associates promptly and accurately respond to all patient billing questions and concerns.
• Facilitates and provides educational materials, training programs, and presentations to enhance understanding of the appeals and grievances process.
• Coaches and mentors other colleagues in techniques, processes, and responsibilities for effectively handling member complaints and appeals.
• Trains junior-level staff to promote the development of departmental capabilities.

For this role you will need Minimum Requirements

- Preferred 3-5 years of experience in a Customer Service

role.

- Experience in reading or researching benefit language

- Medicare and/or Medicaid knowledge

- At least 5 years of experience that includes but is not

limited to claim platforms, products, and benefits;

patient management; product or contract drafting;

compliance and regulatory analysis; special

investigations; provider relations; customer service or

audit experience

- Ability to work in fast paced environment

- Excellent verbal and written communication skills.

- Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics.

- Solution driven and can handle complex issues with accuracy.

- Availability to work alternating weekends for oversight of analysts on alternate schedule.

Education

• High school diploma or equivalent required.   

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.  
 

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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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