Medical Claim Analyst

CVS Health•Work At Home-Virginia, VA

3d•$19 - $35•Remote

About The Position

The Medical Claim Analyst is responsible for the initial review and triage of claims assigned for review. The role determines coverage, verifies eligibility, identifies and redirects misdirected claims, prepares authorizations in the system, and triages cases to medical staff. The analyst organizes and prioritizes work to meet regulatory and claim turnaround times, supports communication among internal and external partners, performs non-medical research and support, and assists with research and resolution of claim payment issues. The position requires adherence to medical management policies and regulatory standards, accurate and complete documentation that meets risk management, regulatory, and accreditation requirements, and protection of member confidentiality. This is a full-time, work-from-home role. Employees must work from the state and city where they have confirmed residence and meet the company's home-workspace, internet, security, and technical requirements. The company provides computer equipment such as a keyboard, monitor, computer, and headset; employees provide their own workspace furniture.

Requirements

Effective communication, telephonic, and organizational skills.
Familiarity with basic medical terminology and concepts used in care.
Strong customer service skills, including attentiveness, sensitivity to issues, and proactive identification and resolution of issues to promote positive member outcomes.
Computer literacy and ability to navigate internal and external computer systems, including Excel and Microsoft Word.
Ability to obtain and maintain a direct, hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 50 Mbps download and 5 Mbps upload; Wi-Fi and satellite internet are not permitted.
Ability to maintain a quiet, secure, private, tidy, and organized designated home workspace compliant with company and HIPAA guidelines, and work without interruption during work hours.
Must work within the state and city where the employee has confirmed current residence.
Ability to use multiple monitors and navigate multiple applications simultaneously.
Ability to communicate using email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 applications (Teams, Outlook, Word, Excel, PowerPoint) or similar tools such as Google Workspace.
Ability to access secure systems such as VPN and EHR portals, secure devices and passwords, and recognize suspicious emails or links.
Ability to resolve common technical issues independently and contact IT for issues that cannot be resolved.
Openness to learning new skills as the workplace environment evolves.
High school diploma or GED.

Nice To Haves

2–4 years of experience as a medical assistant, office assistant, or claim processor.
Experience with CEC/GPS or MedCompass.

Responsibilities

Review and triage claims assigned for review.
Determine coverage and verify eligibility; identify and redirect misdirected claims.
Prepare authorizations in the system and triage cases to medical staff for review.
Organize and prioritize work to meet regulatory and claim turnaround times.
Promote internal and external communication to support effective medical management services and the health care team.
Perform non-medical research and support.
Comply with medical management policies and regulatory standards.
Maintain accurate and complete documentation meeting risk management, regulatory, and accreditation requirements.
Protect member confidentiality and follow company confidentiality policies.
Assist in researching and resolving claim payment issues.