Medical Claims Analyst

CVS Health

1d • $19 - $42 • Remote

About The Position

The Medical Claims 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 for review. The analyst organizes and prioritizes work to meet regulatory and claim turnaround times, supports communication with internal and external parties, performs non-medical research and support, and assists in researching and resolving claims 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 confidential member information. This is a work-from-home position with specified internet, home workspace, technology, security, and communication requirements. The company provides computer equipment and related peripherals; the employee supplies workspace furniture.

Requirements

• Effective communication, telephonic, and organizational skills.
• Familiarity with basic medical terminology and concepts used in care.
• Strong customer service skills, including attention to customers, sensitivity to issues, and proactive identification and resolution of issues.
• Computer literacy and ability to navigate internal and external computer systems, including Excel and Microsoft Word.
• Ability to meet the work-from-home internet requirements: a direct wired connection to a modem/router within 7 feet of the computer, with at least 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 suitable for uninterrupted work.
• Work-from-home colleagues must work within the state and city where they have confirmed they currently live.
• Ability to provide workspace furniture, such as a desk or standing desk, and remain at a desk for extended periods.
• Ability to set up and use multiple monitors and navigate multiple applications simultaneously.
• Ability to communicate using digital channels, including email, calendar invitations, Teams messaging, and virtual meetings.
• Ability to use Microsoft Office 365 applications or similar tools such as Google Workspace.
• Ability to access secure systems such as VPNs and EHR portals, lock an unattended computer, manage strong passwords, and recognize suspicious emails or links.
• Ability to resolve common technical issues independently and contact IT for unresolved issues.
• Openness to learning new skills as the workplace environment evolves.
• High school diploma or G.E.D.

Nice To Haves

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

Responsibilities

• Review and triage claims assigned for review.
• Determine coverage, verify eligibility, and 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.
• Adhere to medical management policies and regulatory standards.
• Maintain accurate and complete documentation that meets risk management, regulatory, and accreditation requirements.
• Protect the confidentiality of member information and follow company confidentiality policies.
• Assist with research and resolution of claims payment issues.

Benefits

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources, based on eligibility.
• Eligibility for a CVS Health bonus, commission, or short-term incentive program.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED