Senior Analyst, Complaints & Appeals (Medicare and/or Commercial) - Remote

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.

Job Summary:

The Sr. Analyst, Complaints & Appeals is responsible for performing quality reviews and audits of appeals, complaints, and grievance resolutions and root cause analysis to determine if cases were handled in accordance with CMS, state and/or federal guidelines and regulations and ensure member experience. Prepares information on audit findings, and provides insights on data, training, process, and program updates for either Medicare or Commercial Line of Business. The role develops reports, dashboards, and key performance indicators to support business decision-making and regulatory compliance. The analyst collaborates with cross-functional stakeholders to investigate issues, conduct root cause analyses, implement corrective actions, and improve operational effectiveness. The position requires strong analytical, problem-solving, communication, stakeholder management, and decision-making skills and supports multiple projects within a fast-paced healthcare environment.

Primary Job Duties & Responsibilities:

1. Perform quality reviews and analysis of grievance and appeal resolutions to determine compliance with CMS, state, and federal regulations and ensure a consistent member experience.

2. Apply in-depth knowledge to conduct end-to-end quality reviews, and analysis while identifying opportunities to improve outcomes and operational performance.

3. Conduct root cause analysis, identified trends, analyzed operational data, and developed recommendations to reduce complaint, grievance, and appeal drivers.

4. Analyze complaint, appeal, overturn, and operational performance data to identify trends impacting customer experience, claims outcomes, and business performance.

5. Lead root cause analysis and governance activities for complaint and appeal issues, including issue identification, validation, corrective action planning, remediation tracking, and development of findings and recommendations to support leadership decision-making, operational improvements, and sustainable resolution of recurring issues.

6. Develop and maintain process documentation, job aids, governance materials, and operational guidance while serving as a subject matter expert, providing analytical support, facilitating knowledge sharing, and contributing to training and continuous improvement initiatives that enhance complaint and appeal operations.

7. Prepare reports, dashboards, presentations, and leadership summaries to communicate audit findings, operational risks, trend analysis, and process improvement opportunities.

8. Identify process gaps, operational defects, and compliance risks and developed recommendations to improve quality performance, administrative efficiency, and customer experience.

9. Partner with cross-functional teams including Operations, Compliance, Clinical, Claims, Product, and Technology to improve resolution quality, operational processes, work instructions, and member experience.

10. Develop actionable insights from appeal trends, and root cause analyses to support leadership decision-making, governance reviews, and continuous improvement initiatives.

Required Qualifications:

• 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.
• Demonstrated ability to collaborate across multiple business functions and influence stakeholders.
• Advanced proficiency with Microsoft Excel, Microsoft PowerPoint, reporting tools, and data analysis methodologies.

Preferred Qualifications:

• Medicare Advantage, Part D, Grievance, CTM, Commercial Appeals, Provider Appeals, Claim operations, Grievance experience or Appeals experience.
• Knowledge of CMS regulations and Medicare complaint and appeal requirements.
• Knowledge of quality management, operational governance, and remediation tracking practices.
• Experience supporting governance, remediation tracking, and operational improvement initiatives.
• Knowledge of healthcare regulations, quality programs, and complaint and appeal workflows.
• Experience with automation initiatives, reporting optimization, or business intelligence solutions.
• Experience supporting executive-level reporting and operational performance reviews.

Education:

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