Medical Claims Reviewer

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 colleagues who care deeply, innovate with purpose, hold themselves accountable, and prioritize safety and quality in everything they do.

Job Overview Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing.

Responsibilities

• Handles and processes benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines.
• Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope.
• Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements.
• Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims.
• Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution.
• Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.
• Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies.
• Analyzes claims data and generates reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.

Requirements

• 1+ year working experience in a customer service environment
• Working knowledge of problem-solving and decision-making skills

Preferred Qualifications

• 1+ years of experience with medical claim processing
• 1+ years of experience in a production environment
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently
• Effective communication, organizational, and interpersonal skills

Education

• High school diploma or equivalent required

Benefits 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.

Pay Range $17.00 - $28.46