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
The Senior Claims Research Coordinator is essential in driving claims adjudication projects and assisting with healthcare analytics, including (but not limited to), pulling and/or validation of claims data for submission to various departments, as well as the state of Illinois. This role focuses on claims management and ensuring effective and accurate claims processing. With an understanding of QNXT (or other claims payer system platforms) and a strong healthcare background, this coordinator will take charge of reviewal, initiation, and submission of high dollar claims projects, as well as conducting root cause analysis where necessary, in order to determine drivers for claim issues. The individual will provide essential technical support and claims processing insights to both external clients and internal stakeholders, including executive leadership.
The Senior Claims Research Coordinator position requires a proactive individual with a strategic mindset, eager to deploy their expert claims knowledge and analytical skills to enhance our healthcare information and claims management systems. Additionally, the role demands a meticulous approach to data validation, manipulation, preparation, and complex analysis, in order to document activities and produce insightful & impactful outcomes in the claims space.
Core Responsibilities
- Conduct comprehensive research and data analysis, ensuring the highest level of data quality and insightful reporting on claim drivers/outcomes.
- Utilize advanced understanding of medical claims processing, leveraging this knowledge to support and innovate within the claims analysis function.
- Establish and maintain a strategic consultative relationship with both internal teams and external clients, becoming the go-to expert for claims analysis and development.
- Offer authoritative oversight and feedback on data quality, directly contributing to service improvement and design advancement.
- Execute dedicated research and root cause analysis to pinpoint issues within the claims process and recommend evidence-based solutions.
- Perform other duties as needed.
Required Qualifications
- 2+ years of experience with claims processing, including a demonstrated familiarity with automated medical claims payment systems and/or payer systems (i.e. Facets, QNXT, etc.)
- 2+ years of experience in data interpretation and analysis, including utilizing SQL to pull and manipulate large data sets, coupled with the ability to interpret and manipulate those same data sets.
- Willingness to work Monday-Friday from 8am-5pm CST.
- Willingness to travel up to 10% of the time within the continental United States.
Preferred Qualifications
- Previous experience with state Medicaid, particularly in Illinois.
- Superlative communication abilities, encompassing both verbal and written formats, to clearly convey complex information and recommendations.
- Proven track record of configuration experience within a claims system environment.
- In-depth research abilities and significant experience in conducting root cause analysis in claims or related fields.
- An aptitude for working independently, as well as part of a team, with a keen eye for detail and problem-solving.
- Knowledge and experience with SQL-type programs for the purpose of pulling specific claim files and validating accuracy.
Education
- Associate’s degree or equivalent work experience (high school diploma or GED + 2+ years of relevant experience).
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$46,988.00 - $122,400.00This 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Skills Required
- 2+ years of experience with claims processing and familiarity with automated medical claims payment systems or payer systems (e.g., Facets, QNXT).
- 2+ years of experience in data interpretation and analysis, including using SQL to pull and manipulate large data sets.
- Willingness to work Monday-Friday from 8am-5pm CST.
- Willingness to travel up to 10% within the continental United States.
- Associate's degree or equivalent work experience (high school diploma or GED + 2+ years relevant experience).
- Previous experience with state Medicaid, particularly Illinois.
- Configuration experience within a claims system environment.
- Strong written and verbal communication skills to convey complex information.
- In-depth research abilities and experience conducting root cause analysis in claims or related fields.
- Ability to work independently and as part of a team with strong attention to detail.
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.
