SIU Senior Claims Coordinator

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

• Works under the direction of the Special Investigations Leadership to prevent, detect and investigate known or suspected acts of fraud, and acts of a criminal nature that involve Aetna Medicaid Providers/Members fraud for the purpose of protecting the employees, assets and resources of the Company.
• Review pre-specified claims for potentially fraudulent activity and return those claims to the claim operations team for proper adjudication.
• Responsible for initial intake of medical records and coordination of the record review.
• Assists SIU Investigators on complex and sensitive investigations.
• Communicates with Medical Directors and other Aetna personnel to clarify review determinations and billing appropriateness.
• Completes projects timely and within state timelines requirements

REQUIRED QUALIFICATIONS

• 2+ years of claims processing or prior medical claim analyst experience.
• Demonstrates the ability to handle multiple assignments competently, accurately and efficiently
• Delivers excellent customer service to colleagues and external partners (health plans, state regulators, law enforcement, etc.).
• Strong analytical and research skills, proficiency in researching information and identifying resources.
• Proficient in Microsoft Excel
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

PREFERRED QUALIFICATIONS

• QNXT experience preferred
• Ability to utilize company systems to obtain relevant electronic documentation (ECHS, Alchemy, Claim Central, Medcompass, QNXT, Availity or HRP)
• Strong verbal and written communication skills

EDUCATION

• High school diploma or equivalent

Please refer the Job description for details