Analyst, Complaint & Appeals
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What you'll do
- Receive, review, classify, investigate, and resolve integrated appeals and grievances
- Independently manage standard, expedited, and highly complex cases from intake through closure.
- Determine appropriate case categorization, regulatory pathway, and applicable turnaround requirements.
- Ensure all cases are accurately documented and maintained in accordance with regulatory and audit requirements.
- Conduct outreach to members, providers, representatives, and internal stakeholders as necessary.
- Manage inventory to ensure all regulatory and departmental timeliness requirements are met
What they're looking for
- Knowledge of Medicare Advantage, Medicaid Managed Care, D-SNP, HIDE, FIDE, and Applicable Integrated Plan grievance and appeal requirements.
- Understanding of CMS regulations, state Medicaid requirements, and fair hearing processes.
- Strong analytical and investigative skills.
- Ability to interpret regulations and apply them to operational casework.
- Excellent written and verbal communication skills.
- Strong organizational and time-management abilities.
- Proficiency with case management systems, reporting tools, and Microsoft Office applications.
- Ability to manage multiple priorities while maintaining accuracy and timeliness.
Nice to have
- 2-5 years of experience in Appeals, Grievances, Utilization Management, Compliance, Quality, Claims, Healthcare Operations, or related healthcare functions.
- Experience working with Medicare and/or Medicaid regulations.
- Experience handling regulatory casework and member correspondence preferred
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
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.
Position Summary
The Integrated Appeals & Grievance Analyst is responsible for the end-to-end management of Medicare, Medicaid, Dual Eligible Special Needs Plan (D-SNP), and Integrated Plan grievances and appeals. The analyst serves as the primary case owner, ensuring timely, accurate, and compliant resolution of member and provider concerns while adhering to federal, state, contractual, and organizational requirements.
This position supports a member-centric integrated model by managing appeals and grievances across Medicare and Medicaid benefit structures, coordinating investigations, issuing regulatory notices, documenting case activity, and partnering with operational, clinical, compliance, and quality teams to ensure regulatory compliance and exceptional member experience
- Receive, review, classify, investigate, and resolve integrated appeals and grievances
- Independently manage standard, expedited, and highly complex cases from intake through closure.
- Determine appropriate case categorization, regulatory pathway, and applicable turnaround requirements.
- Ensure all cases are accurately documented and maintained in accordance with regulatory and audit requirements.
- Conduct outreach to members, providers, representatives, and internal stakeholders as necessary.
- Manage inventory to ensure all regulatory and departmental timeliness requirements are met
Required Qualifications
- Knowledge of Medicare Advantage, Medicaid Managed Care, D-SNP, HIDE, FIDE, and Applicable Integrated Plan grievance and appeal requirements.
- Understanding of CMS regulations, state Medicaid requirements, and fair hearing processes.
- Strong analytical and investigative skills.
- Ability to interpret regulations and apply them to operational casework.
- Excellent written and verbal communication skills.
- Strong organizational and time-management abilities.
- Proficiency with case management systems, reporting tools, and Microsoft Office applications.
- Ability to manage multiple priorities while maintaining accuracy and timeliness.
Preferred Qualifications
- 2-5 years of experience in Appeals, Grievances, Utilization Management, Compliance, Quality, Claims, Healthcare Operations, or related healthcare functions.
- Experience working with Medicare and/or Medicaid regulations.
- Experience handling regulatory casework and member correspondence preferred
Education
- Associates degree or equivalent combination of education and experience.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$21.10 - $44.99This 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.
Company
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