Senior Analyst, Complaints & Appeals – Medicare/Commercial

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🕒 Ontem

🦌 Connecticut – Remoto

🦌 Connecticut – Remote

💵 $46.988 - $112.200 / ano

⏰ Tempo Integral

🟠 Sênior

🧐 Analista

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CVS Health

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1963

🏥 Saúde

⚕️ Seguro de Saúde

🛒 Varejo

Healthcare • Healthcare Insurance • Retail

CVS Health é uma empresa líder de saúde nos Estados Unidos, dedicada a ampliar o acesso e a acessibilidade ao cuidado. A empresa adota uma abordagem abrangente que inclui serviços de saúde, seguro saúde e gestão de benefícios farmacêuticos (PBM). Por meio de suas subsidiárias, como Aetna e CVS Caremark, a CVS Health oferece uma variedade de serviços que promovem o bem-estar, a gestão de condições de saúde e a cobertura acessível de medicamentos prescritos. A CVS Health opera farmácias de bairro, oferece serviços de farmácia por correspondência e gerencia programas de medicamentos de especialidade, com o objetivo de tornar o cuidado com a saúde conveniente e acessível para todos. Movida pela missão de conectar pessoas a serviços essenciais de cuidado, a CVS Health está comprometida em fomentar comunidades mais saudáveis e apoiar o bem-estar de todas as pessoas.

Descrição

• Perform quality reviews and analysis of grievance and appeal resolutions for compliance with CMS, state, and federal regulations • Conduct end-to-end quality reviews and identify opportunities to improve outcomes and operational performance • Conduct root cause analyses, identify trends, analyze operational data, and develop recommendations to reduce complaint, grievance, and appeal drivers • Analyze complaint, appeal, overturn, and operational performance data to identify trends affecting customer experience, claims outcomes, and business performance • Lead root cause analysis and governance activities, including issue identification, validation, corrective action planning, remediation tracking, and findings and recommendations • Develop and maintain process documentation, job aids, governance materials, and operational guidance • Serve as a subject matter expert, provide analytical support, facilitate knowledge sharing, and contribute to training and continuous improvement initiatives • Prepare reports, dashboards, presentations, and leadership summaries communicating audit findings, operational risks, trend analysis, and process improvement opportunities • Identify process gaps, operational defects, and compliance risks and recommend improvements • Partner with Operations, Compliance, Clinical, Claims, Product, and Technology teams to improve resolution quality, operational processes, work instructions, and member experience • Develop actionable insights to support leadership decision-making, governance reviews, and continuous improvement initiatives

🎯 Requisitos

• 3–5 years of experience in healthcare operations, complaints and appeals, analytics, quality, compliance, governance, risk management, or related functions • Strong analytical, problem-solving, and decision-making skills • Experience conducting trend analysis, root cause analysis, operational reviews, and process improvement initiatives • Experience developing reports, dashboards, and executive-level presentations • Strong written and verbal communication skills • Ability to collaborate across multiple business functions and influence stakeholders • Advanced proficiency with Microsoft Excel, Microsoft PowerPoint, reporting tools, and data analysis methodologies • Preferred: Medicare Advantage, Part D, Grievance, CTM, Commercial Appeals, Provider Appeals, Claim operations, Grievance or Appeals experience • Preferred: Knowledge of CMS regulations and Medicare complaint and appeal requirements • Preferred: Knowledge of quality management, operational governance, and remediation tracking practices • Preferred: Experience supporting governance, remediation tracking, and operational improvement initiatives • Preferred: Knowledge of healthcare regulations, quality programs, and complaint and appeal workflows • Preferred: Experience with automation initiatives, reporting optimization, or business intelligence solutions • Preferred: Experience supporting executive-level reporting and operational performance reviews • Bachelor's degree preferred or equivalent combination of education, professional experience, and relevant healthcare operational expertise

🏖️ Benefícios

• CVS Health bonus, commission or short-term incentive program in addition to base pay range • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being