Description
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 we do.
Position Summary Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.
Responsibilities:
- Perform adjustments across all dollar amount levels on customer service platforms using technical and claims processing expertise.
- Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
- Perform claim re-work calculations.
- Follow through completion of claim overpayments, underpayments, and any other irregularities.
- Process complex non-routine Provider Refunds and Returned Checks.
- Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks.
- Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
- Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures.
- Review and handle relevant correspondences assigned to the team that may result in adjustment to claims.
- May provide job shadowing to lesser experience staff.
- Utilize all resource materials to manage job responsibilities
Required Qualifications
- 2+ years medical claim processing experience.
- Experience in a production environment.
- Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
- Effective communications, organizational, and interpersonal skills.
Preferred Qualifications
- DG system claims processing experience.
- Associate degree preferred.
Education
- High School Diploma or GED.
Anticipated Weekly Hours 40
Time Type Full time
Pay Range $18.50 - $42.35
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.