At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
- Performs research of complex claim reviews post-adjudication to ensure claims are processed per published policies, procedures and regulatory guidelines. This includes end-to-end claim adjudication and worktask review for legal, regulatory, and audit requests from internal and external customers.
- Will be a key resource in auditing functions for the Medicare and IFP lines of business.
- May perform or assist with special projects, perform analysis of data to identify and communicate quality trends or gaps in policy.
- Consult and/or work cross functionally to influence and promote change in order to continually deliver quality service to our internal and external customers.
- Provides Leadership/Coaching/Mentoring; may be a mentor to others.
- Analyzes complex claims for trends, highlights in-depth interpretations and provides in-depth root cause analysis for claim adjudication. This includes policy, contract, and pricing reviews to ensure correct claim handling.
- Translates complex data into constructive data and information and makes recommendations.
- Illustrates complex information in a clear concise manner.
- Develops and conducts presentations and consultations to existing and prospective customers and internal business areas.
- Provides workgroup support on projects.
- Influences changes/enhancements to business processes, policies, and system infrastructure to improve information quality, availability and access.
Required Qualifications
Medicare Claims Processing Experience/ IFP Claims Processing Experience
Preferred Qualifications
Excellent verbal and written communication skills. Extensive experience with databases as well interpretation and manipulation of related data. Healthcare background. 3-5 years of data interpretation and analysis experience.
Education
Bachelor's degree, technical certification or equivalent work experience.
- Job Families for Job Profiles
Business Compliance
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$43,888.00 - $102,081.00
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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
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Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
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No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
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Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 04/03/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
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