Senior Manager – Complaint & Appeals

This is a fully remote position, open to applicants in United States.

📋 Description

• Lead and oversee a team focused on addressing complaints and appeals

• Ensure adherence to federal and/or state regulations

• Create policies, procedures, and programs to ensure regulatory compliance

• Develop audit tools to verify the integrity, timeliness, and accuracy of Complaint and Appeals data reporting

• Manage daily operations, budget oversight, staff development, audit preparedness, training, documentation, and procedures

• Address compliance risks and formulate strategies for mitigation

• Define business requirements for applications related to complaints and appeals systems

• Authorize system monitoring for the timeliness of appeal cases and the entire workflow

• Coordinate with internal, external, and cross-functional partners regarding the handling of provider appeals

• Collaborate with Compliance, Legal, Project Management, IT, Staff Development, and other departments

• Ensure accountability for quality, training, and production metrics

• Assess training requirements and create necessary resources

⛳️ Requirements

• A minimum of 3 years of experience in managed care

• At least 2 years of experience in Appeals and Grievance

• Experience with NCQA or EQRO Audits

• Bachelor's degree preferred, along with specialized training or relevant professional qualifications

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program

• Opportunity for awards in the company’s equity award program

• Medical coverage

• Dental coverage

• Vision coverage

• Paid time off

• Retirement savings options

• Wellness programs

• Additional resources to support physical, emotional, and financial well-being