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.

Research and process grievances and appeals for Dual eligible members and providers. Perform outreach to obtain additional information. Interact with Medical Directors and Nurses as well as Leadership.

Required Qualifications

• Prior experience as a Complaint and Appeal Analyst.
• Must have experience processing health insurance grievance and appeal cases
• 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.
• 0-2 years work experience

Preferred Qualifications
Medicare and Medicaid appeal and grievance preferred

Education
High School Diploma or GED requiredPay 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.

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 HealthWe anticipate the application window for this opening will close on: 01/31/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.