Hispanic Alliance for Career Enhancement
Complaint and Appeals Senior Coordinator
Hispanic Alliance for Career Enhancement, New Bremen, Ohio, United States
At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues—caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
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.
What you will do
Review and process appeals filed by participating providers.
Assist with adherence to regulatory requirements, conduct internal audits, and address any identified compliance issues with the Complaint and Appeals policies and procedures.
Draft and send appeal decision letters.
Provide peer support to coordinators when handling complex appeal issues.
Serve as SME for handling complex cases such as CA IPA or SIU cases.
Maintain successful performance to meet 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.
Education
High School Diploma (REQUIRED).
Bachelor's Degree or equivalent experience (PREFERRED).
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 our comprehensive and competitive mix of pay and benefits—investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options,
a
401(k) plan
(including matching company contributions), and an
employee stock purchase plan .
No-cost programs for all colleagues
including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues
including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 01/30/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues—caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
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.
What you will do
Review and process appeals filed by participating providers.
Assist with adherence to regulatory requirements, conduct internal audits, and address any identified compliance issues with the Complaint and Appeals policies and procedures.
Draft and send appeal decision letters.
Provide peer support to coordinators when handling complex appeal issues.
Serve as SME for handling complex cases such as CA IPA or SIU cases.
Maintain successful performance to meet 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.
Education
High School Diploma (REQUIRED).
Bachelor's Degree or equivalent experience (PREFERRED).
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 our comprehensive and competitive mix of pay and benefits—investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options,
a
401(k) plan
(including matching company contributions), and an
employee stock purchase plan .
No-cost programs for all colleagues
including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues
including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 01/30/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
#J-18808-Ljbffr