Job Description SummaryDevelops and manages a team to address matters regarding complaints and appeals, ensuring compliance with federal and/or state regulations. Leads the development of policies, procedures, and programs to ensure compliance with policies of all applicable federal and/or state government agencies
What you will do- Create audit tools to validate Complaint and Appeals data integrity, timeliness, and accuracy of data outputs for all Complaint and Appeals reporting.
- Control day-to-day operational oversight of highly performing teams, budget management, staff development, audit readiness, staff training, documentation and execution, and procedure documentation.
- Follow up on compliance risks and works to develop mitigation strategies to address identified issues to ensure compliance with these regulations.
- Establish business requirements for system applications to support complaints and appeals based on business needs or change in regulatory requirements.
- Approve systems for monitoring the timeliness of appeals cases from end-to-end, ensuring workflow procedures are met to achieve company goals.
- Communicate with both internal, external, and cross-functional partners to ensure the ability to serve appropriate and timely review of provider appeals handling.
- Collaborate with Compliance, Legal, Project Management, IT, Staff development, and various other internal departments to support operational initiatives.
- Allocate accountability for ensuring staff is held accountable to quality, training, and production metrics to ensure a high level of customer satisfaction and loyalty.
- Analyze training needs to develop appropriate resources and successfully enhance the company's competitive advantage in the industry.
For this role you will need Minimum Requirements- 3+ years experience in managed care
- 2+ years of Appeal and Grievance Experience
- NCQA or EQRO Audit experience
Education- Bachelor's degree preferred/specialized training/relevant professional qualification.
Pay RangeThe typical pay range for this role is:
$75,400.00 - $165,954.00
This 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. This position also includes an award target in the company's equity award program.
Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 09/01/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
