Claim Benefit Specialist-Medical Reviewer
About The Position
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 Performs claim documentation review, verifies policy coverage, assesses policy application validity, communicates with healthcare providers, policyholders and beneficiaries to ensure accurate and timely handling of the medical review process. Contributes to the efficient and accurate handling of medical and final expense claims for reimbursement through knowledge of medical records reviews, team processes, and effective communication skills. A Brief Overview Performs medical records ordering and review, verifies policy coverage, evaluate health conditions in relation to policy requirements and application answers, assesses claim validity, communicates with healthcare providers, policyholders and beneficiaries to ensure accurate and timely medical records review. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical records reviews, team processes, and effective communication skills.
Requirements
- HS Diploma or equivalent
- Knowledge of MS word and excel
- Strong analytical and decision-making skills
Nice To Haves
- 1-2 years’ experience reviewing medical records
- Medical coding knowledge
Responsibilities
- Orders, handles and reviews medical records for contestable claims, ensuring accuracy, efficiency, and adherence to policies and guidelines.
- Determines the eligibility and coverage of benefits for each policy based on the patient's insurance plan, health conditions, the scope of coverage, and policy guidelines.
- Documents claim with medical records information in the system, assigning appropriate codes and other necessary data elements to ensure accurate tracking, reporting, and processing of claims in all appropriate applications.
- Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution.
- Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.
- Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies.
- Provides regular, timely feedback to frontline claims analysts to drive effective delivery of exceptional services and competencies.
Benefits
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
