Senior Coordinator Complaint Appeals Operations

CVS Health • Oregon, Oregon • 1w 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

Biomedical Equipment Support Specialist (Information Systems)

Veterans Affairs, Veterans Health Administration • California, California • 2h ago

Hospital & Medical

Summary The Biomedical Equipment Support Specialist (BESS) (Biomedical Information Systems) provides clinical and administrative support to staff, patients, and administrators for all matters of concern relating to the f...

2h ago

Go to Apply

Buyer

Nuclear Fuel Services • Virginia, Virginia • 2h ago

Retail & Hospitality

At BWX Technologies, Inc. (NYSE: BWXT), we are People Strong, Innovation Driven. A U.S.-based company, BWXT is a Fortune 1000 and Defense News Top 100 manufacturing and engineering innovator that provides safe and effect...

2h ago

Go to Apply

AEGIS Missile Software Engineer

AeroVironment • Virginia, Virginia • 2h ago

IT & Engineering

Worker Type Regular Job Description Summary As a Software Engineer III (Applications) one works with and is mentored by a talented group of engineers in a fast moving, collaborative Agile development environment. In this...

2h ago

Go to Apply

Part Sales Manager - Part Time

AutoZone, Inc. • Michigan, Michigan • 3h ago

Management & Administrative

Job Description AutoZone's Store Management team drives store performance, fosters a productive team, and ensures exceptional customer service. Managers and MITs play a key leadership role, expected to Live The Pledge an...

3h ago

Go to Apply

Senior Engineer Build and DevOps - ADI

NVIDIA • California, California • 8h ago

IT & Engineering

NVIDIA is widely considered to be one of the world's most desirable employers. We have some of the most forward-thinking and hardworking people in the world working for us. If you're creative and autonomous, we want to h...

8h ago

Go to Apply

Operations Manager , Last Mile - Operations

Amazon • Tennessee, Tennessee • 8h ago

Management & Administrative

Description At Amazon, we're working to be the most customer- eccentric company on earth. To get there, we need exceptionally talented, bright, and self driven people. Amazon is seeking Team leads for our transportation...

8h ago

Go to Apply

Banking & Capital Markets Tax Director

PwC • California, California • 9h ago

Finance, Accounting & Banking

Specialty/Competency: Industry Tax Practice Industry/Sector: Banking and Capital Markets Time Type: Full time Travel Requirements: Up to 20% At PwC, our people in tax services focus on providing advice and guidance to cl...

9h ago

Go to Apply

Banking Advisor III - PNC Private Bank

PNC • Ohio, Ohio • 9h ago

Finance, Accounting & Banking

Position Overview At PNC, our people are our greatest differentiator and competitive advantage in the markets we serve. We are all united in delivering the best experience for our customers. We work together each day to...

9h ago

Go to Apply

Administrative Law Examiner 13-P15 (Limited-Term)

State of Michigan • Michigan, Michigan • 14h ago

Legal & Paralegal

Administrative Law Examiner 13-P15 (Limited-Term) Print ( https://www.governmentjobs.com/careers/michigan/jobs/newprint/5235123 ) Apply ? Administrative Law Examiner 13-P15 (Limited-Term) Salary $33.53 - $63.10 Hourly Lo...

14h ago

Go to Apply

A1A Service Advocate

CVS Health • Ohio, Ohio • 14h ago

Management & Administrative

14h 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.