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.
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Position Summary
Fast, accurate claims payment is one of the ways we make a difference in people's lives. Claims professionals work directly with members, doctors and employer groups, providing a friendly and knowledgeable voice at the other end of the phone at times when it's most needed.
Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems
Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Handles phone and written inquiries related to requests for preapprovals/pre-authorizations, reconsiderations, or appeals. Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures. Identifies and reports possible claim overpayments, underpayments and any other irregularities. Performs claim re-work calculations. Makes outbound calls to obtain required information for first claim or reconsideration. Trained and equipped to support call center activity if required, including general member and/or provider inquiries.
Required Qualifications
1-2 Years within the following;
Experience in a production environment. Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
Oral and written communication skills. Ability to maintain accuracy and production standards. Technical skills. Analytical skills.
Preferred Qualifications
2+ years claim processing experience. Claim processing experience.
Understanding of medical terminology. Strong knowledge of benefit plans, policies and procedures
Education
HS Diploma
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$17.00 - $28.46
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.
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: 04/22/2025
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.
