Medical Claim Analyst
Posted on: 11 Dec 2023
Frankfort, KY
Job Description
Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
Position Summary
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 reviewto 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.
Required Qualifications
2+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately and efficiently.
Customer service experience
Knowledge of Medical Terminology
Education
High School Diploma or equivalent GED.
Pay Range
The typical pay range for this role is:
CVS Health
Woonsocket, RI
CVS Health Corporation provides health services and plans in the United States. Its Pharmacy Services segment offers pharmacy benefit management solutions, such as plan design and administration, formulary management, retail pharmacy network management, mail order pharmacy, specialty pharmacy and infusion, Medicare Part D, clinical, disease management, and medical spend management services. The company’s Retail/LTC segment sells prescription drugs and general merchandise, such as over-the-counter drugs, beauty products, cosmetics, and personal care products, as well as provides health care services through its MinuteClinic walk-in medical clinics.
Its Health Care Benefits segment offers traditional, voluntary, and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, medical management, Medicare plans, PDPs, Medicaid health care management services, workers’ compensation administrative services, and health information technology products and services. The company’s customers include employers, insurance companies, unions, government employee groups, health plans, Medicare Part D prescription drug plans, Medicaid managed care plans, plans offered on public health insurance exchanges and private health insurance exchanges, other sponsors of health benefit plans, individuals, college students, workers, labor groups, and expatriates.
As of December 31, 2018, it had approximately 40 leased on-site pharmacies, 25 leased retail specialty pharmacy stores, 20 specialty mail order pharmacies, and 90 branches for infusion and enteral services; and 9,900 retail locations and 1,100 MinuteClinic locations, as well as operated an online retail pharmacy Websites, LTC pharmacies, and onsite pharmacies. The company was formerly known as CVS Caremark Corporation and changed its name to CVS Health Corporation in September 2014. CVS Health Corporation was founded in 1963 and is headquartered in Woonsocket, Rhode Island.
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IndustryHealthcare
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No. of Employees295, 000
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Website
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Jobs Posted4287
