Claim Audit Quality Specialist

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

Claim Audit Quality Analyst is responsible for ensuring the accuracy and quality of claim audits across multiple areas within Meritain. This role demands a deep understanding of claims, plan documents, eligibility, coverages, and the unique requirements of various groups. The analyst will become a subject matter expert, applying detailed review skills and maintaining high standards in a fast-paced, high-production environment.

Job description:

• Conduct thorough audits of claims, ensuring compliance with plan documents and eligibility requirements.
• Analyze and interpret a variety of group-specific guidelines and coverage “quirks”.
• Maintain high accuracy and quality standards while meeting production goals.
• Manage time effectively to balance multiple priorities in a deadline-driven setting.
• Collaborate with team members to share knowledge and resolve complex audit issues.
• Document audit findings clearly and provide actionable feedback.

Required Qualifications:

• 1-3 years of claims processing

• 1+ year(s) Knowledge of CPT codes

• 1+ year(s) Knowledge of ICD-10 codes

• Microsoft office experience.

Preferred Qualifications:

• 1–2 years of DG experience
• Strong knowledge of claims processing
• Exceptional attention to detail
• Ability to quickly become a subject matter expert in new areas
• Proven track record of managing workload efficiently in a high-volume environment

Education:

• High School diploma

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• 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

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.