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.

POSITION SUMMARY

The Senior Claim Data Specialist handles end-to-end processes associated with claim data management. This person identifies and addresses issues impacting auto-adjudication levels, claim accuracy, and alignment with internal and external (regulatory) policy.

REQUIRED QUALIFICATIONS:

• 2+ years of experience with medical claims and/or claims processing.
• At least 1 year of experience with medical coding.
• Expert knowledge in Microsoft Suite applications (Teams, Outlook, Word, Excel, etc.).
• Must reside in Oklahoma.

PREFERRED QUALIFICATIONS:

• Previous experience with QNXT, Remedy, and/or SQL.
• Knowledge of Oklahoma Medicaid Program.
• Previous experience in technical writing.
• Previous experience in creating workflows.
• Previous experience in working remotely.
• Demonstrated successful project completion, specifically within a team environment.
• Demonstrated analytical and strategic thinking; ability to output analysis into easily digestible summaries.
• Ability to prioritize tasks based on type and impact.
• Ability to pivot quickly with competing priorities.
• Demonstrated adaptability, with a keen ability to work in a matrixed and potentially high-stress environment.
• Cross-departmental communication skills.
• Demonstrated professionalism, in both verbal and written communications.
• Strong knowledge of benefit plans.
• Ability to work collaboratively.
• Ability to spot trends quickly and accurately.
• Ability to take initiative as needed.
• Demonstrated problem-solving skills.
• Previous experience with creating and analyzing reports.

EDUCATION

• High school diploma or GED.

• Handle phone and written inquiries from internal teams regarding claims adjudication outcomes, systems benefit configuration issues, appeals, and operations workflows.
• Ensure all compliance requirements are satisfied and that all payments are made against company practices and procedures.
• Identify, report, and prevent possible claim overpayments, underpayments, and any other irregularities.
• Perform claims re-work calculations.
• Review and submit requests for auto-adjudication.
• Review and resolve pended claims with provider and/or billing data mismatches.
• Occasionally make outbound calls, in collaboration with Provider Services, to offer provider education.
• Perform review of submitted claims and configuration projects and results.
• Report financial impact of completed tasks.
• Look at trends in data and perform subsequent analysis.
• Make recommendations as needed and address risks based on research and analysis.
• Perform other duties as assigned.