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Position Summary
Medical Claim Analyst for the Clinical Claim Review department is responsible for post – service claim review to determine if specific services can be reimbursed to providers.
Responsibilities
- The analyst role is integral to the Clinical Claim Review (CCR) team.
- They start the Clinical Claim Review process with the claim submission to Clinical Claim Review 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.
- 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.
Required Qualifications
- 2+ years of claim processing experience and/or demonstrating ability to handle multiple assignments competently, accurately, and efficiently.
Preferred Qualifications
- Customer service experience preferred
- Computer literacy in order to navigate through internal/ external computer systems, including Excel and Microsoft Word.
- Effective communication, telephonic and organization skills.
- Strong customer service skills.
- Ability to effectively participate in a multi-disciplinary team
Education
- High School Diploma
Pay Range
The typical pay range for this role is:
$18.50 – $36.30
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.
