Description

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 Senior Ops Coordinator reviews and processes appeals filed by participating providers, ensures adherence to regulatory requirements, and addresses compliance issues related to Complaint and Appeals policies. This role conducts internal audits, drafts appeal decision letters, and serves as a subject matter expert (SME) for complex cases.

This position can be anywhere in the United States.

What you will do

• Review and process appeals filed by participating providers.
• Assist with adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
• Drafts and sends appeal decision letters.
• Provide peer support to coordinators when handling complex appeal issues.
• Serves as SME for handling complex cases such as CA IPA or SIU cases.
• Maintain successful performance for meeting monthly metrics for attendance, production and quality.
• Provide training and ongoing support to new hires to ensure successful onboarding and integration into team processes.

Required Qualifications

• 2+ years in appeals, compliance, or a related coordination role
• Proven success in meeting monthly metrics for attendance, production and quality.
• Strong knowledge of regulatory requirements and compliance standards
• Excellent written and verbal communication skills
• Ability to support and mentor peers on complex issues
• Proficiency with relevant software and case management tools

Preferred Qualifications

• Medicare experience
• Claims experience
• Experience in reading or researching benefit language in Summary Plan Description (SPDs) or Certificate of Coverage (COCs)
• Experience in research and analysis of claim processing is a plus

Education

• Bachelor's degree or equivalent experience

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$18.50 - $31.72

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.

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.

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: 04/28/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.