Senior Coordinator Complaint Appeals Operations

CVS Health; Austin (TX); On-site; USD 25,485 - 48,615; Full time

Benefits offered by this job

Affordable medical plan options

401(k) plan with company matching

Employee stock purchase plan

Wellness programs and financial coaching

Flexible work schedules

Job summary

A leading health solutions company in Austin, Texas, is seeking a Senior Coordinator for Complaint Appeals Operations. This role involves researching and resolving various appeals, coordinating cross-departmental efforts, and addressing complaints. Candidates should possess strong communication skills and knowledge of Medicare. The position offers full-time hours and a competitive salary range, alongside comprehensive benefits aimed at investing in employees' well-being.

Qualifications

• Excellent verbal and written communication skills are essential.
• Demonstrated ability to handle multiple assignments competently and efficiently.
• Medicare knowledge or experience is required.

Responsibilities

• Research and resolve incoming electronic appeals as a single-point-of-contact.
• Coordinate efforts internally and across departments to resolve claims research.
• Identify trends and emerging issues to provide reports and input.

Skills

Excellent verbal and written communication skills

Excellent customer service skills

Medicare knowledge/experience

Education

High School Diploma

Job description

Senior Coordinator Complaint Appeals Operations

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.

Position Summary

• Research and resolves incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal.
• Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work.
• Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures.
• Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial.
• Can review a clinical determination and understand rationale for decision.
• Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process.
• Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise.
• Identifies trends and emerging issues and reports on and gives input on potential solutions.
• Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required.
• Understands and can respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned.

Required Qualifications

• Excellent verbal and written communication skills.
• Excellent customer service skills.
• Medicare knowledge/experience.

Preferred Qualifications

• 1-2 years Medicare part C Appeals experience.
• Experience in reading or researching benefit language in SPDs or COCs.
• Experience in research and analysis of claim processing a plus.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• Experience documenting workflows and reengineering efforts.
• Project management skills are preferred.

Education

High School Diploma

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The Typical Pay Range For This Role Is

$18.50 - $35.29

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.

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, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 12/31/2025

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

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Management and Manufacturing

Industries

• Hospitals and Health Care