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.
This position is available nationwide, as it is a fully remote position.
Position Summary
Provide support to the Supervisors by coaching, mentoring and training new staff. Oversight over inventory.
• 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
• 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.
Required Qualifications
- 2-4 years of experience in a Customer Service role.
- 2-4 years of Medicare and/or Medicaid knowledge.
- At least 2-4 years of experience that includes but is not limited to clinical and claim platforms, benefits and services. In addition; Compliance and regulatory knowledge; provider relations and customer service.
- Experience in reading or researching benefit language.
- Ability to work in fast paced 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.
- Availability to work alternating weekends for oversight of analysts on alternate schedule.
Preferred Qualifications
- Audit experience
- Critical thinking experience.
- Ability to work complex issues
- Team Player
- Exhibit How We Work Behaviors
- Solution Driven
Education
- High School Diploma or GED required or 2-4 years of equivalent work experience
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$18.50 - $38.82This 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.
Skills Required
- 2-4 years of experience in a Customer Service role.
- 2-4 years of Medicare and/or Medicaid knowledge.
- 2-4 years experience with clinical and claim platforms, benefits and services, compliance and regulatory knowledge, provider relations and customer service.
- Experience reading or researching benefit language (Evidence of Coverage, plan design).
- Ability to work in a fast paced environment.
- Excellent verbal and written communication skills.
- Excellent organizational skills to handle high inventory and meet metrics.
- Solution driven and able to handle complex issues with accuracy.
- Availability to work alternating weekends for oversight of analysts.
- High School Diploma or GED or 2-4 years of equivalent work experience.
- Audit experience.
- Critical thinking experience.
- Team player and ability to work cross-functionally.
CVS Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CVS Health and has not been reviewed or approved by CVS Health.
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Healthcare Strength — Health coverage includes medical, dental, and vision with HSA-eligible options, free preventive care, virtual care, and access to MinuteClinic services. Mental-health resources such as counseling support are emphasized, and coverage is often considered solid for full-time colleagues.
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Retirement Support — A dollar-for-dollar 401(k) match up to 5% after one year and an Employee Stock Purchase Plan are consistently highlighted in Total Rewards materials. Feedback suggests retirement programs are a meaningful strength within the overall package.
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Wellbeing & Lifestyle Benefits — Wellbeing offerings include up to 20 no-cost counseling sessions per issue, backup care, tuition assistance, and substantial in-store discounts, alongside broader wellness tools. These everyday perks expand value beyond base pay and can be especially meaningful for full-time schedules.
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What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
