Support members and providers by managing complex appeals and complaints, ensuring timely, accurate, and customer-focused resolutions—all from the comfort of your home.
About CVS Health
CVS Health is the nation’s leading health solutions company, connecting millions of Americans with affordable, convenient, and compassionate care. With more than 300,000 colleagues nationwide, we are building a healthier future together.
Schedule
- Full-time, 40 hours per week
- Remote, but must reside in Pennsylvania
- Standard business hours with occasional flexibility to meet program deadlines
Responsibilities
- Manage appeals and complaint cases as a single point of contact, researching and resolving complex issues.
- Review plan design, certifications of coverage, and contractual agreements to ensure appropriate benefit determinations.
- Investigate claims, payments, and member eligibility data before initiating the appeal process.
- Educate team members and act as a subject matter expert on workflows, appeals processes, and fiduciary responsibilities.
- Coordinate efforts across multiple departments to resolve claims, benefit interpretation, and regulatory requirements.
- Respond to escalated appeals, including those from regulators, executive offices, or state/federal agencies.
- Identify trends and provide input on solutions to improve processes.
- Deliver quality reviews, prepare documentation for audits, and support customer and regulatory meetings.
Requirements
- High School Diploma required
- At least 1 year of experience reading or researching benefit language in SPDs or Certificates of Coverage
- Strong problem-solving and organizational skills
- Excellent verbal and written communication skills
- Ability to manage multiple assignments accurately and efficiently
- Proven leadership qualities and ability to document and reengineer workflows
Preferred Qualifications
- 1 year of experience in claims research and analysis
- 1–2 years of Medicare Part C appeals experience
- Project management experience a plus
- Strong knowledge of specialty case types
Benefits
- Competitive pay: $18.50 – $35.29 per hour
- Affordable medical, dental, and vision coverage
- 401(k) with company match + employee stock purchase plan
- Paid time off and flexible scheduling options
- Family leave, dependent care resources, and tuition assistance
- Wellness screenings, confidential counseling, and financial coaching
- Comprehensive growth and career development opportunities
Join CVS Health and play a critical role in resolving appeals and protecting member rights while ensuring compassionate care delivery.
Happy Hunting,
~Two Chicks…