Coordinator, Complaint & Appeals (Remote)

CVS Health; Town of Woodstock (NY); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading health solutions company is seeking a candidate to manage appeals and grievances. The role includes regulatory compliance oversight, documentation of queries, and educating staff on processes. The ideal candidate will have experience with HMO and Traditional claims and a strong background in patient management. Flexible work location across the United States offered.

Benefits

Affordable medical plan options

401(k) plan with matching contributions

Employee stock purchase plan

Tuition assistance

Qualifications

• 1 year experience with HMO and Traditional claim platforms.
• Experience in patient management and regulatory analysis.

Responsibilities

• Reviews and processes appeals and grievances.
• Conducts internal audits for compliance.
• Prepares educational materials on appeals processes.
• Coaches junior colleagues on standard procedures.

Skills

HMO and Traditional claim platforms experience

Patient management

Compliance and regulatory analysis

Customer service

Education

High School or Equivalent

Job description

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.

Overview

Position Summary

Schedule: Monday-Friday 7:00am-3:30pm

A Brief Overview

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.

What You Will Do

• Reviews, and processes appeals and grievances filed by patients.
• Assists with adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
• Conducts reviews of decisions and case files to determine if there are errors in the application of law or evidence.
• Drafts and sends appeal decision letters.
• Identifies key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process.
• Documents patient billing questions and concerns.
• Prepares educational materials, training programs, or presentations to enhance understanding of the appeals and grievances process.
• Coaches junior colleagues on best practices and standard operating procedures.
• Assists with the training of junior-level staff to promote the development of departmental capabilities.

Responsible for managing to resolution complaint/appeal scenarios for all products, which may contain multiple issues and may require coordination of responses from multiple business units. Ensure timely, customer focused response to complaints/appeals. Identify trends and emerging issues and report and recommend solutions. This position can be anywhere in the United States.

Required Qualifications

• 1 year experience that includes both HMO and Traditional claim platforms, products, and benefits, patient management, product, compliance and regulatory analysis, special investigations, provider relations, customer service or audit experience.

Preferred Qualifications

• Medicare experience
• Claims experience
• Experience in reading or researching benefit language in Summary Plan Description (SPDs) or Certificate of Coverage (COCs)
• Experience in research and analysis of claim processing a plus.

Education

High School or Equivalent

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The Typical Pay Range For This Role Is $17.00 - $31.30

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.

Benefits

• 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 jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 10/17/2025

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