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.

ACCOUNTABILITIES

• Develop and implement strategies for claim editing, including identifying areas for improvement and implementing new technologies or processes
• Oversees the development, implementation, and maintenance of clinical claim editing rules and processes.
• Works cross-functionally with other departments, such as product management, operations, and technology, to ensure seamless execution and delivery of new edits
• Ensure that medical claims are reviewed and edited according to established guidelines and regulations, such as the National Correct Coding Initiative (NCCI) Edits and Correct Coding or ICD-10-CM Edits.
• Track and analyze key metrics related to claim editing, such as clean claim rates and denial rates, and develop action plans to improve performance.
• Stay up-to-date on regulatory changes and ensure that claim editing processes are compliant with all applicable laws and regulations.
• Oversee third-party vendors ensuring that the software is functioning correctly.
• Identifying opportunities to reduce unnecessary payments and improve the efficiency of the claims process.
• Identifies and implements process improvements to optimize efficiency and accuracy in claim editing
• Directs, mentors, and motivates a team of claim edit specialists and other professionals.

REQUIRED SKILLS

• Strong understanding of the healthcare industry, including medical management, claims processing, and provider networks.
• Extensive knowledge and experience in clinical claim editing, including the development, implementation, and maintenance of claim editing rules and processes.
• Strong analytical skills with the ability to identify trends and insights from claim edit data.
• Strong understanding of regulatory requirements related to claims processing.

PREFERRED SKILLS

• Proficient in working autonomously and thriving under pressure, demonstrating the ability to prioritize tasks effectively, meet deadlines, and exhibit strong organizational and problem-solving capabilities, along with follow-up skills.
• Exhibits a strong commitment to detail, ensuring accuracy and thoroughness in all tasks. Possesses exceptional project management abilities.
• Highly skilled in Microsoft Office applications, including Teams, PowerPoint, and Excel.
• Demonstrates strong written and verbal communication skills, with an emphasis on customer service excellence.
• Proven ability to lead, motivate, and develop teams.
• Excellent communication and interpersonal skills, including the ability to communicate complex information to both internal and external stakeholders.
• Experience in process improvement and workflow optimization.
• Highly organized, proficient in managing tasks and adept at balancing multiple responsibilities seamlessly.
• Skilled in navigating a collaborative and often ambiguous work environment, fostering strong interpersonal relationships.
• Possesses a clear understanding of decision-making authority and responsibilities.

EDUCATION & EXPERIENCE

• Bachelor’s of Nursing in a related field, such as healthcare administration, business, or a related field.
• Certified Professional Coder through AAPC or AHIMA (Physician, Facility or Payer) a plus or willing to pursue within two years, preferred
• 5-7 years working experience in a health plan managing clinical claim editing program including knowledge of these platforms: ACAS and/or HRP Claim review and expertise.
• Commercial, Medicare and IFP expertise/experience around the product and line of business
• 3+ years in project program management
• 3-4 leadership experience