Medical Claim Analyst

CVS Health•Work At Home-Ohio, OH

2d•Onsite

About The Position

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. Position Summary CCR is responsible for post - service claim review to determine if specific services can be reimbursed to providers and members. - The analyst role is integral to the CCR team. -They start the CCR process with the claim submission to CCR with a complete review of the claim and claim history. They compile all system information, claim history, plan information, and any additional research into template as required by the workflow and any legal and regulatory requirements for a clinician review. -They also collaborate with Medical Directors as required. -Review provider and member claims to determine if they meet CCR review requirements. -Follow applicable workflows, templates, and legal and compliance requirements to provide a complete picture of what is requiring review to the CCR clinicians and medical directors. -Organizes and prioritizes work to help meet regulatory and CCR claim turn around times. Determines coverage, verifies eligibility, benefits, identifies discrepancies and applies all Medical Claim Management policies and procedures to assist in ensuring claims are handled per policy and legal requirements. -Works with all appropriate internal and external departments and personnel to accurately review specified claims and/or clarify any issues found in the course of the review. -Required to work in multiple systems including EWM, ASD, ATV, MedCompass and HRP. -Other systems dependent on specific reviews criteria. -Maintains and utilizes all resource materials and systems to effectively manage job responsibilities Adheres to company policies to protect member confidentiality.

Requirements

2+ years experience and demonstrated ability to handle multiple assignments competently, accurately and efficiently.
Required to work in multiple systems including EWM, ASD, ATV, MedCompass and HRP.
Other systems dependent on specific reviews criteria.

Nice To Haves

Knowledge of utilization management rules and regulations and claim processing guidelines.
Claims Processing/ customer service experience preferred

Responsibilities

Review provider and member claims to determine if they meet CCR review requirements.
Follow applicable workflows, templates, and legal and compliance requirements to provide a complete picture of what is requiring review to the CCR clinicians and medical directors.
Organizes and prioritizes work to help meet regulatory and CCR claim turn around times.
Determines coverage, verifies eligibility, benefits, identifies discrepancies and applies all Medical Claim Management policies and procedures to assist in ensuring claims are handled per policy and legal requirements.
Works with all appropriate internal and external departments and personnel to accurately review specified claims and/or clarify any issues found in the course of the review.
Maintains and utilizes all resource materials and systems to effectively manage job responsibilities
Adheres to company policies to protect member confidentiality.