Senior Coordinator Complaint Appeals Operations

CVS Health • Pennsylvania, Pennsylvania • 6d ago

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Position Summary

Responsible for managing to resolution appeal scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. May have contact with outside plan sponsors or regulators.

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.

Serves as point person for newer staff in answering questions associated with claims/customer service systems and products. Educates team mates as well as other areas on all components within member or provider/practitioner complaints/appeals for all products and services.

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:

1 years' experience in reading or researching benefit language in SPDs or COCs

Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Excellent verbal and written communication skills.

Computer navigation ability and ability to multitask.

Excellent customer service skills.

Strong Leadership skills

Experience documenting workflows and reengineering efforts.

Preferred Qualifications:

1 years of experience in research and analysis of claim processing.

1-2 years Medicare part C Appeals experience.

Education:

High School Diploma

Anticipated Weekly Hours

Time Type

Full time

Pay Range

The typical pay range for this role is:

$18.50 - $42.35

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.

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: 02/08/2026

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

CVS Health is an equal opportunity/affirmative action employer, including Disability/Protected Veteran - committed to diversity in the workplace.

Similar Jobs

Restaurant Leader (Manager) Trainee

7-Eleven • Clairton, PA • 1h ago

Retail & Hospitality

Restaurant Leader (Manager) Trainee Apply Now ( https://my7elevenhr.wd12.myworkdayjobs.com/Careers/job/Store-45745-CLAIRTON-PA/Restaurant-Leader--Manager--Trainee\R26\812/apply ) Save Job Job ID R26_812 Store-ID 45745 Ad...

1h ago

Go to Apply

Restaurant Manager

Shake Shack • United States, United States • 1h ago

Retail & Hospitality

Our secret to leading the way in hospitality? We put our people first! At Shake Shack, our mission is to Stand For Something Good in all that we do. From our teams to our neighborhoods, we're committed to always doing th...

1h ago

Go to Apply

Cook

Accura Healthcare • United States, United States • 1h ago

Retail & Hospitality

Accura HealthCare of O'Neill is seeking a Cook to join our dining services team. Utilizing culinary and customer service skills, Cooks prepare nutritious meals while forming meaningful relationships that positively impac...

1h ago

Go to Apply

Teppanyaki Chef

SARKU JAPAN • Pittsburgh, PA • 1h ago

Retail & Hospitality

Teppanyaki Chef, a full-time postion at Sarku Japan Restaurant in Pittsburgh, PA. Duties: Prepare Japanese style cuisine on teppanyaki tables in an open kitchen; ensure all dishes are cooked according to company recipes...

1h ago

Go to Apply

Supervisor, Construction Crew

Centuri Group, Inc. • Houston, PA • 1h ago

Trucking & Construction

Supervisor, Construction Crew Date: Feb 12, 2026 Location: Houston, PA, US, 15342 Company: NPL Construction (S4) Description: Who We Are Centuri Group is comprised of a family of companies that make up a utility infrastr...

1h ago

Go to Apply

Traveling Assistant Superintendent, Construction

ARCO • United States, United States • 1h ago

Trucking & Construction

ABOUT YOU Ready to experience a better way to build your career? ARCO hires only the best and brightest dedicated to providing our clients with superior solutions, cultivating our award-winning workplace culture, and dri...

1h ago

Go to Apply

Aviation Construction Project Manager

City of San Antonio • United States, United States • 1h ago

Trucking & Construction

Aviation Construction Project Manager Print ( https://www.governmentjobs.com/careers/sanantoniotx/jobs/newprint/5234191 ) Apply ? Aviation Construction Project Manager Salary $64,097.02 - $96,145.66 Annually Location TX...

1h ago

Go to Apply

Supervisor, Construction Crew

NPL Construction • Houston, PA • 1h ago

Trucking & Construction

1h ago

Go to Apply

Principal Data Center Construction Manager

Oracle • Harrisburg, PA • 1h ago

Trucking & Construction

Job Description The Data Center Infrastructure Construction team at Oracle Cloud Infrastructure is a dynamic group of professionals dedicated to delivering state-of-the-art data center facilities at scale and at pace. Th...

1h ago

Go to Apply

PTC TCI - Transportation Construction Inspector

PRIME AE GROUP INC • King Of Prussia, PA • 1h ago

Trucking & Construction

Help Us Change the World---One Project at a Time At PRIME AE, we believe every bridge, building, classroom, park, and roadway we design tells a story---and leaves a legacy. Whether it's through architecture, engineering,...

1h ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.