Medical Claim Analyst

at  CVS Health

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

POSITION SUMMARY

The Medical Claim Analyst role is responsible for analyzing submitted documentation, making efforts to obtain required information, and processing Medicare and Commercial claims per CMS, state and other regulations. This position requires a methodical attention to detail, strong analytic thinking, and the ability to multi-task in a production based and time sensitive environment.

Additional responsibilities include the following but not limited to the following:

• Responsible for initial review and triage of claims tasked for review.
• Determines coverage, verifies eligibility, identifies and redirects misdirects
• Responsible for prepping the authorization in the system and triage cases to medical staff for review.
• Organized and prioritizes work to meet regulatory and claim turn-around times
• Promotes communication, both internally and externally to enhance effectiveness of medical management services and health care team.
• Performs non-medical research and support
• Adheres to Compliance with PM Policies and Regulatory Standards.
• Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
• Assist in the research and resolution of claims payment issues

Required Qualifications

• 2 plus years experience as a medical assistant, office assistant, or claim processor

• Benefits Management - Understanding Clinical Impacts, General Business

• ATV, ASD, MedCompass

• Familiarity with basic medical terminology and concepts used in care .
• Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.

• Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word

• Applying Reasoned Judgment -Claim - Payment management, Claim - Policies & procedures, Clinical / Medical - General Management

PREFERRED QUALIFICATIONS

• Ability to effectively participate in a multi-disciplinary team including internal and external participants.
• Effective communication, telephonic and organization skills.

EDUCATION

High School Diploma or equivalent G.E.D

• Responsible for initial review and triage of claims tasked for review.
• Determines coverage, verifies eligibility, identifies and redirects misdirects
• Responsible for prepping the authorization in the system and triage cases to medical staff for review.
• Organized and prioritizes work to meet regulatory and claim turn-around times
• Promotes communication, both internally and externally to enhance effectiveness of medical management services and health care team.
• Performs non-medical research and support
• Adheres to Compliance with PM Policies and Regulatory Standards.
• Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
• Assist in the research and resolution of claims payment issue