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:
TheSr. Analyst, Complaints & Appealsis responsible for performing quality reviews and audits of appeals, complaints, and grievance resolutions and root cause analysis to determine ifpre-servicecases were handled in accordance with CMS, state and/or federal guidelines and regulations and ensure memberand providerexperience. Prepares information on audit findings, settles disputes, and provides insights on data, potential audit risks, training, process, and program updates for Medicare,Commercialandother applicableLine of Businesses. 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:
Perform quality reviews and audits of grievance and appeal resolutions todeterminecompliance with CMS, state, and federal regulations and ensure a consistent member experience.
Conduct root cause analysis,identifiedtrends, analyzed operational data, and developed recommendations to reduce complaint, grievance, and appeal drivers.
Analyzecomplaint, appeal,overturn, and operational performance data toidentifypre-servicetrendsimpactingcustomerand providerexperience, and business performance.
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.
Develop andmaintainprocess documentation, job aids, governance materials, and operational guidance while serving as a subject matter expert, providing analytical support,facilitatingknowledge sharing, and contributing to training and continuous improvement initiatives that enhance complaint and appeal operations.
Prepare reports, dashboards, presentations, and leadership summaries to communicate audit findings, operational risks, trend analysis, and process improvement opportunities.
Evaluate audit findings andprovidedguidanceregardingcorrective actions necessary to achieve departmental qualityobjectivesand regulatory requirements.
Support governance activities byvalidatingroot cause findings, monitoring remediation efforts, and evaluating the effectiveness of corrective actions.
Serve as a subject matter expert on quality standards, regulatory requirements, operational processes, and performance measurement.
Identifyprocess gaps, operational defects, and compliance risks and developed recommendations to improve quality performance, administrative efficiency, and customer experience.
Partner with cross-functional teams including Operations, Compliance, Clinical, Product, and Technology to improve resolution quality, operational processes, work instructions, and member experience.
Develop actionable insights from audit reviews, complaint and appeal trends, and root cause analyses to support leadership decision-making, governance reviews, and continuous improvement initiatives.
Support projects focused on process optimization, reporting enhancements, regulatory compliance, operational effectiveness, and reduction of recurring complaint and appeal drivers.
Required Qualifications:
3-5 years of experience in healthcare operations, complaints and appeals, analytics, quality, compliance, governance, risk management, or related functions.
Strong analytical, problem-solving, and decision-making skills.
Experience conducting trend analysis, root cause analysis, operational reviews, and process improvement initiatives.
Experience developing reports, dashboards, and executive-level presentations.
Strong written and verbal communication skills.
Demonstrated ability to collaborate across multiple business functions and influence stakeholders.
Advancedproficiencywith Microsoft Excel, Microsoft PowerPoint, reporting tools, and data analysis methodologies.
Preferred Qualifications:
Medicare Advantage, Part D, Grievance, CTM, Commercial Appeals, Provider Appeals,Utilization Management experience,Grievance experience or Appeals experience.
Knowledge of CMS regulations and Medicarecomplaintand appeal requirements.
Knowledge ofPre-service andPrior Authorizationprocedures and workflows
Knowledge of quality management, operational governance, and remediation tracking practices.
Experience supporting governance, remediation tracking, and operational improvement initiatives.
Knowledge of healthcare regulations, quality programs, and complaint and appeal workflows.
Experience with automation initiatives, reporting optimization, or business intelligence solutions.
Experience supporting executive-level reporting and operational performance reviews.
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
The boar re-runs this search every day and emails you what’s new — scraped straight from company career sites, no recruiter spam. Free.