Grievance and Appeals- Quality Analyst - Fully Remote

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

Applies in-depth knowledge of subject matter and independently coaches others on matters regarding complaints and appeals, ensuring compliance with federal and/or state regulations. Ensures compliance with policies of all applicable federal and/or state government agencies, including but not limited to the Center for Medicaid and Medicare (CMS), Department of Public Welfare, Department of Health, and Department of Insurance.
What you will do

• Prepares and participates in external and internal audits.
• Analyzes basic quality and completeness of the complaints and appeals documentation to ensure the accuracy, clarity, and compliance of the information provided, including supporting documentation, timelines, and required forms or processes.
• Contributes to process improvements by recommending complaint and appeal process changes, as well as new training programs to drive quality results.
• Assists in analyzing patterns, trends, and systemic issues, working with other teams to address all complaints, and escalating more complex issues and concerns to upper management for resolution.
• Compiles reports on quality metrics in order to contribute to the overall improvement of service delivery and customer satisfaction.
• Facilitates simple inquiries, providing updates, and maintaining a customer-centric approach to enhance satisfaction and promote positive experiences.
• Carries out simple tasks for compliance audits by gathering documentation, providing evidence of compliance, and assisting auditors during the review process.
• Receives and implements regular, timely feedback to ensure delivery of exceptional services and engagement, motivation, and team development.
• Acts as a liaison between the organization and relevant individuals, providing updates, explanations, and clarifications throughout the process under close supervision.

Required Qualifications

• 1+ years of Compliance experience
• 1+ years of External Audit Experience
• 1+ years of Grievance and Appeals Experience

Education

• High School Diploma or GED

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$21.10 - $36.78

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

We anticipate the application window for this opening will close on: 05/02/2025

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