Medicare Clinical Appeals Analyst

CVS Health; United States; Remote; USD 80,000 - 100,000; Full time

Job summary

A leading health solutions company seeks a Medicare Clinical Appeals Analyst to support operations in their Medicare Advantage plan appeals department. This fast-paced role requires strong organizational skills, proficiency in computer systems, and the ability to communicate effectively. Candidates will assist in various administrative tasks and collaborate with a team to address operational needs and challenges.

Benefits

Affordable medical plan options

401(k) plan with company matching

Employee stock purchase plan

Wellness screenings and tobacco cessation programs

Tuition assistance and flexible work schedules

Qualifications

• Must possess a High School Diploma or equivalent.
• Proficiency in multiple systems and keyboarding required.
• Exceptional written, verbal, and digital communication skills.

Responsibilities

• Support day-to-day operations for Medicare Advantage plan appeals.
• Assist with inventory management strategies and administrative tasks.
• Collaborate with colleagues to address urgent or complex issues.

Skills

Organizational skills

Communication skills

Proficiency with computer skills

Education

High School Diploma

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.

Medicare Clinical Appeals Analyst Position Summary
The Clinical Appeals Analyst position requires an individual to be task oriented supporting day-to-day operations for the par provider Medicare Advantage plan appeals department. This is a fast-paced department that requires working independently in conjunction with a team environment.

Role Description/Outline of Responsibilities (includes but not limited to):

Role Requirements:

• Accountable to leadership for support of the day-to-day operations of the team to meet business needs by assisting with various administrative tasks as requested by leadership.
• Demonstrates a solid understanding of workflows, policies, and procedures.
• Assist with inventory management strategies to appropriately triage, assign, or assist with high volume inventory and at leadership’s discretion to meet business needs.
• Contribute to, participate in leadership, and colleague meetings.
• Ability to follow checklists, keep accurate track of assigned work systematically, & prioritize work.
• Must be comfortable in a fast-paced environment.

Eligibility/Requirements:

• High School Diploma or equivalent High School Exam Required.
• Internal job posting that requires completion of the application and interview process.
• Requires proficiency with computer skills including navigating multiple systems and keyboarding.
• Time efficient and highly organized.
• Exceptional written, verbal, and digital communication skills.
• Flexibility to shift tasks.
• Ability to prioritize urgent tasks.

Role Description/Outline of Responsibilities (i ncludes but is not limited to)

• Ability to meet deadlines in a deadline intensive environment.
• High level of adaptability and willingness to embrace change in a fast-paced, demanding environment.

• Escalate urgent or complex issues to leadership as needed.
• Assist as necessary if escalated with the return of invalid/inappropriate/incorrect/incomplete cases to Coordinators.
• Assist as necessary if escalated updates for OTs (admin OTs, short TATs, batch cases, etc.).
• Triage appeals requesting missing components and collaborating with both business partners and providers.
• Excellent written and verbal professional communication skills.
• Collaborate with colleagues including MDs, Managers, Supervisors, Team Leads, Clinical Nurses, admin, and peers.

Quality Management:

• Identify potential job aide updates or workflow changes and escalate to upper management.

• Trend opportunities for weekly meetings and/or monthly huddles.
• Monitor turn-around times ensuring appeals meet compliance deadlines.

Inventory glidepath & compliance:

• Monitor for and coordinate the management of urgent/late cases with short TAT.
• Workload Balance by assigning appeals to the MDs.
• Workload Balance by assigning appeals to nurses ongoing daily systematically.
• Cross train with business partners to assist.
• Assist assigning and closing out cases that ICC cannot work.

SARS Coordinator

• Collaborate with the Associate Managers & TLs for new hire for system access onboarding
• Request MH, MC, Rumba, GPS, HRP etc., through NEAT V2 tool, AccessNow, & QuickBase.
• Keep SARS Spreadsheet updated and accurate in live time
• Add the new colleagues' entries to the PTO QuickBase.
• Clarify equipment to order and/or return.
• Assist with:
• setting up outlook folders
• add/remove/edit team distribution lists
• access to clinical team fax folder
• Set up H drive folders
• Set up OneNote
• installing apps like RightFax, ABBY, RUMBA etc.

Miscellaneous

• Manage time accurately in Work brain (non-exempt employee) for weekly worked hours, PTO, OT etc.
• Run reports.
• Collaborate with peers coordinating time off meeting department policies.
• Assist with various stretch roles and projects including but not limited to:
  • RCA
  • CPT code QuickBase
  • MD Access requests

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$21.10 - $44.99

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. 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, visithttps://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 07/11/2025

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