Work From Home, US
Remote only
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.
Job Summary:
The Sr. Analyst, Complaints & Appeals is responsible for performing quality reviews and audits of appeals, complaints, and grievance resolutions and root cause analysis to determine if cases were handled in accordance with CMS, state and/or federal guidelines and regulations and ensure member experience. Prepares information on audit findings, and provides insights on data, training, process, and program updates for either Medicare or Commercial Line of Business. The role develops reports, dashboards, and key performance indicators to support business decision-making and regulatory compliance. The analyst collaborates with cross-functional stakeholders to investigate issues, conduct root cause analyses, implement corrective actions, and improve operational effectiveness. The position requires strong analytical, problem-solving, communication, stakeholder management, and decision-making skills and supports multiple projects within a fast-paced healthcare environment.
Primary Job Duties & Responsibilities:
1. Perform quality reviews and analysis of grievance and appeal resolutions to determine compliance with CMS, state, and federal regulations and ensure a consistent member experience.
2. Apply in-depth knowledge to conduct end-to-end quality reviews, and analysis while identifying opportunities to improve outcomes and operational performance.
3. Conduct root cause analysis, identified trends, analyzed operational data, and developed recommendations to reduce complaint, grievance, and appeal drivers.
4. Analyze complaint, appeal, overturn, and operational performance data to identify trends impacting customer experience, claims outcomes, and business performance.
5. Lead root cause analysis and governance activities for complaint and appeal issues, including issue identification, validation, corrective action planning, remediation tracking, and development of findings and recommendations to support leadership decision-making, operational improvements, and sustainable resolution of recurring issues.
6. Develop and maintain process documentation, job aids, governance materials, and operational guidance while serving as a subject matter expert, providing analytical support, facilitating knowledge sharing, and contributing to training and continuous improvement initiatives that enhance complaint and appeal operations.
7. Prepare reports, dashboards, presentations, and leadership summaries to communicate audit findings, operational risks, trend analysis, and process improvement opportunities.
8. Identify process gaps, operational defects, and compliance risks and developed recommendations to improve quality performance, administrative efficiency, and customer experience.
9. Partner with cross-functional teams including Operations, Compliance, Clinical, Claims, Product, and Technology to improve resolution quality, operational processes, work instructions, and member experience.
10. Develop actionable insights from appeal trends, and root cause analyses to support leadership decision-making, governance reviews, and continuous improvement initiatives.
Required Qualifications:
Preferred Qualifications:
Education:
Bachelor's degree preferred or equivalent combination of education, professional experience, and relevant healthcare operational expertise.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$46,988.00 - $112,200.00This 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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