Medical Claim Analyst

CVS Health

3d•$19 - $39

About The Position

The Medical Claim Analyst supports savings optimization for medical claims by inspecting claims and providing accurate claim information. The role responds to customer benefit inquiries, maintains customer service standards, administers medical cost management policies and procedures, and coordinates support functions for claim adjudication. Under limited supervision, the analyst completes routine and non-routine business support tasks and refers deviations from standard practices to managers.

Requirements

Working knowledge of problem-solving and decision-making skills.
Five or more years of work experience.
High school diploma or equivalent.

Responsibilities

Inspect claims and provide accurate claim information to support savings optimization.
Respond to customer inquiries about benefits while maintaining customer service standards.
Administer medical cost management policies and procedures and coordinate support functions for claim adjudication.
Execute routine and non-routine business support tasks for the Medical Claims area, referring deviations from standard practices to managers.
Follow area protocols, standards, and policies to provide effective and timely support.
Review the ECHS report daily to distribute tasks to appeal nurses.
Review provider coding edits routed from non-clinical claims and prepare them for review by an Aetna clinician.
Use CS Hub guidelines to review and process predetermination requests and determine review eligibility.
Process CORR tasks by working or rerouting them as appropriate.
Prioritize work and multitask to balance projected workload and due dates.