Senior Coordinator Complaint Appeals Operations

CVS Health • Rhode Island, Rhode Island • 4d 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

Sales Representative

Travel + Leisure Co. • Newport, RI • 46min ago

Sales & Marketing

We Put the World on Vacation Travel + Leisure Co. is the world's leading vacation ownership and travel membership company, with a dynamic and growing portfolio of resort, travel club, and lifestyle travel brands. Our ded...

46min ago

Go to Apply

In-Home Sales Representative

Bath Planet • Providence, RI • 1h ago

Sales & Marketing

In-Home Sales Representative Transforming Baths with Style, Affordability, and Quality At Bath Planet of Connecticut , we're redefining the way homeowners approach bath remodeling. Offering stylish, cost-effective, and l...

1h ago

Go to Apply

Electrical Engineering Coordinator

System One • North Kingstown, RI • 1h ago

IT & Engineering

Overview The Electrical Engineering/Coordinator is accountable for the preliminary design phase through to final design implementation of all electrical work and equipment. Direct and oversee the day-to-day activities of...

1h ago

Go to Apply

Principal Software Engineer - Impact

Oracle • Providence, RI • 1h ago

IT & Engineering

Job Description As a Principal Engineer inside the Oracle Cloud Infrastructure Media Services team, you will have the opportunity to solve challenging technical problems and function as a lead developer in the developmen...

1h ago

Go to Apply

Principal Software Engineer - Impact

Oracle • Providence, RI • 1h ago

IT & Engineering

1h ago

Go to Apply

Attorney/Lawyer

Robert Half • Warwick, RI • 6h ago

Legal & Paralegal

Description Our client, a successful law firm, is seeking a Litigation Attorney to join their team. The ideal candidate will bring extensive experience in managing complex civil cases, demonstrating exceptional legal exp...

6h ago

Go to Apply

Health Information Specialist I - 5834

Datavant • Providence, RI • 6h ago

Hospital & Medical

Datavant is a data platform company and the world's leader in health data exchange. Our vision is that every healthcare decision is powered by the right data, at the right time, in the right format. Our platform is power...

6h ago

Go to Apply

Customer Experience Representative

Citizens • Johnston, RI • 7h ago

Management & Administrative Sponsored

Starting Salary: $22.00 / hour Start Date: April 13, 2026 When there’s a question about your finances, you want answers and support fast. Our customers rely on our Contact Center Specialists to help them understand, and...

7h ago

Go to Apply

Client Services Rep/Office Services

Citizens • Johnston, RI • 7h ago

Management & Administrative Sponsored

7h ago

Go to Apply

Datacenter Technician -L2

Cognizant • Providence, RI • 7h ago

IT & Engineering

Role: L2 Datacenter Technician Location: Portland, Oregon (Onsite) Require 5-7 years of overall experience working in a Datacenter environment · Diagnose and troubleshoot server issues to identify and isolate root causes...

7h 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.