CDR, Complaint & Appeals

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. **Schedule:** Wednesday-Sunday with a flexible start time between 9am-1pm **Position Summary** Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals. Identify trends and emerging issues and report and recommend solutions. Independently coaches others on appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases coming from internal and external constituents for all products. Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance and State regulators. Understand and adapt to departmental process and policies. Medicare knowledge is a plus. Fast Turn Around of inventory, collaboration with clinical team and management. Attention to detail is needed and must be able to maintain compliance turn-around times, with accurate case resolution or research. Remain a part of the solution by escalating issues that may impact compliance timeliness. Additional duties as assigned which will include a carrying a modified case load including but not limited to: **Additional Responsibility:** + Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements. + Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling. + Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases. + Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases. + Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications. + Additional duties as assigned which will include a carrying a modified case load including but not limited to:-Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria. + Research Standard Plan Design or Certification of Coverage (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. + Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process. + Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria. + Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. + Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services. **Required Qualifications:** + At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience. + 2+ years of Medicare Experience. + Proficient in computer use, including Excel and Electronic Health Records (EHR) systems. **Preferred Qualifications:** + Some Medicare and/or Medicaid knowledge + Experience in reading or researching benefit language + Ability to work in fast paced, high volume environment + Excellent verbal and written communication skills + Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics + Solution driven and can handle complex issues with accuracy **Education:** + High School Diploma or GED **Anticipated Weekly Hours** 40 **Time Type** Full time **Pay Range** The typical pay range for this role is: $17.00 - $34.15 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 We anticipate the application window for this opening will close on: 07/30/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.