Medical Claim Analyst

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

CCR is responsible for post service claim review to determine if specific services can be reimbursed to providers.

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 clinicians as required.

Additional responsibilities to include but not limited to the following :

• Review provider 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.

Required Qualifications

• 2 plus years experience of Healthcare experience
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Preferred Qualifications

• Knowledge of utilization management rules and regulations and claim processing guidelines.
• Claims Processing / customer service experience preferred.

Education

High School Diploma or equivalent GED

Pay Range

The typical pay range for this role is :

$18.50 - $37.02

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.

The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ( PTO ) or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.