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
Reviews and adjudicates complex, sensitive, and/or
specialized claims in accordance with plan processing
guidelines. Acts as a subject matter expert by providing
training, coaching, or responding to complex issues. May
handle customer service inquiries and problems.

Reviews pre-specified claims or claims that exceed
specialist adjudication authority or processing expertise.
 

– Applies medical necessity guidelines, determines
coverage, completes eligibility verification, identifies
discrepancies, and applies all cost containment. measures
to assist in the claim adjudication process.
– Handles phone and written inquiries related to requests
for pre-approval/pre-authorization, reconsiderations, or
appeals.
– Insures all compliance requirements are satisfied and all
payments are made against company practices and
procedures.
– Identifies and reports possible claim overpayments,
underpayments and any other irregularities.
– Performs claim rework calculations.
– Distributes work assignment daily to junior staff.
– Trains and mentors claim benefit specialists.- Makes
outbound calls to obtain required information for claim or
reconsideration.

Required Qualifications
– 2+ years claim processing experience.
– Experience in a production environment.
– Claim processing experience.
– Demonstrated ability to handle multiple assignments
competently, accurately and efficiently.

Preferred Qualifications
– Associates degree

Education
Associates degree or equivalent work experience.

Pay Range

The typical pay range for this role is:

$18.50 – $36.30

This 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. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.