Senior Manager - Complaint & Appeals

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.

Develops 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.

• 3+ years experience in managed care

• 2+ years of Appeal and Grievance Experience

• NCQA or EQRO Audit experience

• Bachelor's degree preferred/specialized training/relevant professional qualification.

The typical pay range for this role is: