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Analyst – Complaint & Appeals
| Company | CVS Health |
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| Location | Texas, USA |
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| Salary | $21.1 – $40.9 |
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| Type | Full-Time |
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| Degrees | Bachelor’s |
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| Experience Level | Mid Level, Senior |
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Requirements
- Prior experience as a Complaint and Appeal Analyst.
- Claim research knowledge or claim processing experience.
- Demonstrated ability to multi-task projects.
- Ability to work independently while researching, performing analysis, and applying resources necessary to complete a final assessment of the required and appropriate action (verbal and/or written).
- Autonomously makes decisions based upon current policies/guidelines.
- Ability to make decisions that ensure business continuity and with awareness of all possible implications and impact.
- Expert knowledge of clinical terminology, and regulatory and accreditation requirements.
- Ability to coach and support others with accuracy and ethical resolution.
- Ability to work collaboratively across the organization both internally and externally.
- Adept negotiation and analytical skills.
- 2-5 years work experience.
Responsibilities
- Serves as a subject matter expert in complaints and appeals, providing independent coaching and guidance to ensure strict adherence to all relevant federal and state regulations.
- Oversees inventory management and trend analysis, proactively investigating and updating policies to resolve escalated cases from internal and external stakeholders across all product lines.
- Maintains compliance with all applicable regulatory agencies, Department of Public Welfare, Department of Health, and Department of Insurance.
- This role is critical in upholding operational integrity and supporting continuous process improvement.
Preferred Qualifications
- Bachelor’s degree or higher in a relevant field (e.g., healthcare administration, business, or related discipline).
- 3+ years of experience in complaints and appeals, case management, or regulatory compliance.
- Demonstrated expertise in interpreting and applying federal and state healthcare regulations (such as CMS guidelines).
- Strong analytical and problem-solving skills, especially with escalated or complex cases.
- Proven ability to coach, mentor, or train others in process or policy.
- Experience managing inventory, trend analysis, or process improvement initiatives.
- Excellent written and verbal communication skills, with a focus on clarity and professionalism.
- Ability to collaborate effectively with cross-functional teams and external stakeholders.
- Advanced proficiency with relevant systems or tools (e.g., case management software, reporting tools).
