Medical Claims Analyst
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 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.
- Verifiable High School Diploma or GED.
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.
- Required to work in multiple systems including EWM, ASD, ATV, MedCompass and HRP.
- Maintains and utilizes all resource materials and systems to effectively manage job responsibilities
- Adheres to company policies to protect member confidentiality.
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.
- For more information, visit https://jobs.cvshealth.com/us/en/benefits
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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
