Senior Analyst, Complaints & Appeals (Pre-service) - 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   pre - service   cases were handled in accordance with CMS, state and/or federal guidelines and regulations and ensure member   and provider   experience. Prepares information on audit findings, settles disputes, and provides insights on data, potential audit risks, training, process, and program updates for Medicare ,   Commercial   and   other applicable   Line of Business es . 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:   Perform quality reviews and audits of grievance and appeal resolutions to   determine   compliance with CMS, state, and federal regulations and ensure a consistent member experience.   Conduct root cause analysis,   identified   trends, analyzed operational data, and developed recommendations to reduce complaint, grievance, and appeal drivers.   Analyze   complaint , appeal,   overturn , and operational performance data to   identify   pre - service   trends   impacting   customer   and provider   experience, and business performance.   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.   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.   Prepare reports, dashboards, presentations, and leadership summaries to communicate audit findings, operational risks, trend analysis, and process improvement opportunities.   Evaluate audit findings and   provided   guidance   regarding   corrective actions necessary to achieve departmental quality   objectives   and regulatory requirements.   Support governance activities by   validating   root cause findings, monitoring remediation efforts, and evaluating the effectiveness of corrective actions.   Serve as a subject matter expert on quality standards, regulatory requirements, operational processes, and performance measurement.   Identify   process gaps, operational defects, and compliance risks and developed recommendations to improve quality performance, administrative efficiency, and customer experience.   Partner with cross-functional teams including Operations, Compliance, Clinical, Product, and Technology to improve resolution quality, operational processes