Medical Claim Analyst

CVS Health Job Opportunity

We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

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 a 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 turnaround 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 review 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+ years experience and 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: Verifiable High School Diploma or GED.

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: The typical pay range for this role is: $18.50 - $38.82. 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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments.