Director, Complaints & Appeals Compliance

CVS Health; Indiana; Hybrid; USD 68,000 - 149,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a Senior Manager to lead a team addressing complaints and appeals, ensuring compliance with applicable federal and state regulations. You will develop policies and programs that align with government agency requirements and CVS Health standards.

The role focuses on building audit tools, overseeing operations, coordinating with Compliance, Legal, IT, and business partners, and driving improvements to ensure timely reviews, data integrity, and high customer satisfaction.

Qualifications

• Minimum 3+ years of managed care experience.
• 2+ years of Appeal and Grievance experience.
• NCQA or EQRO audit experience.

Responsibilities

• Create audit tools to validate Complaint and Appeals data integrity, timeliness, and accuracy of data outputs for all Complaint and Appeals reporting.
• Oversee day-to-day operations of high-performing teams, including budget, staff development, audit readiness, training, and documentation.
• Develop mitigation strategies to address compliance risks and ensure adherence to regulatory requirements.
• Set business requirements for systems supporting complaints and appeals based on regulatory changes.
• Approve systems for monitoring timeliness of appeals cases end-to-end and ensure required workflows.

Skills

Managed care experience

Appeal & Grievance experience

Audit experience (NCQA/EQRO)

Education

Bachelor's degree preferred

Job description

CVS Health is seeking a Senior Manager to lead a team addressing complaints and appeals, ensuring compliance with applicable federal and state regulations. You will develop policies and programs that align with government agency requirements and CVS Health standards.

The role focuses on building audit tools, overseeing operations, coordinating with Compliance, Legal, IT, and business partners, and driving improvements to ensure timely reviews, data integrity, and high customer satisfaction.