Experienced Medical Claims Adjustor – Remote Opportunity for a Dynamic and Compassionate Professional

Are you a detail-oriented and empathetic individual with a passion for delivering exceptional customer service and navigating complex medical claims? Do you thrive in a fast-paced environment where no two days are the same? If so, we invite you to join our team as an Experienced Medical Claims Adjustor at CVS Health, a leading healthcare company dedicated to transforming the way healthcare is delivered.

About CVS Health

At CVS Health, we're committed to putting our heart into every moment of our patients' health. Our purpose is to deliver enhanced human-centric healthcare for a rapidly changing world. With a brand that's anchored in heart, we strive to create a culture that's inclusive, innovative, and empowering. Our Heart At Work Behaviors support this purpose, ensuring that every employee feels empowered to transform our culture and accelerate our ability to innovate and deliver solutions that make healthcare more personal, convenient, and affordable.

Job Summary

As an Experienced Medical Claims Adjustor, you'll play a critical role in reviewing and adjusting SF (Self-funded), FI (Fully insured), Reinsurance, and/or RX claims, as well as handling customer service inquiries and problems. You'll apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Your technical expertise and claims processing skills will enable you to perform adjustments across all dollar amount levels on customer service platforms, ensuring that all compliance requirements are satisfied and that all payments are made following company practices and procedures.

Key Responsibilities

* Review and adjust SF (Self-funded), FI (Fully insured), Reinsurance, and/or RX claims in accordance with claim processing guidelines

• Process provider refunds and returned checks
• Handle customer service inquiries and problems
• Perform adjustments across all dollar amount levels on customer service platforms using technical and claims processing expertise
• Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
• Perform claim re-work calculations
• Follow through completion of claim overpayments, underpayments, and any other irregularities
• Process complex non-routine Provider Refunds and Returned Checks
• Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals
• Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures
• Review and handle relevant correspondences assigned to the team that may result in adjustment to claims
• May provide job shadowing to lesser experience staff
• Utilize all resource materials to manage job responsibilities

Essential Qualifications

* 2+ years of medical claim processing experience

• 2+ years of experience in a production environment
• Associate degree or equivalent experience

Preferred Qualifications

* DG system claims processing experience

• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently
• Effective communications, organizational, and interpersonal skills

Skills and Competencies

* Strong analytical and problem-solving skills

• Excellent communication and interpersonal skills
• Ability to work in a fast-paced environment with multiple priorities
• Strong technical skills, including proficiency in claims processing software and systems
• Ability to maintain confidentiality and handle sensitive information
• Strong attention to detail and accuracy
• Ability to work independently and as part of a team

Career Growth Opportunities and Learning Benefits

At CVS Health, we're committed to helping our employees grow and develop their careers. We offer a range of training and development programs, including:

• On-the-job training and mentorship
• Formal training programs and certifications
• Leadership development programs
• Career advancement opportunities

Work Environment and Company Culture

As a remote employee, you'll have the flexibility to work from the comfort of your own home. Our company culture is built on the principles of inclusivity, innovation, and empowerment. We're committed to creating a workplace that's welcoming and supportive of all employees, regardless of their background or identity.

Compensation, Perks, and Benefits

We offer a competitive salary range of $18.50 - $35.29 per hour, depending on experience. In addition to your compensation, you'll enjoy a range of benefits, including:

• Medical, dental, and vision benefits
• 401(k) retirement savings plan
• Employee Stock Purchase Plan
• Fully-paid term life insurance
• Short-term and long-term disability benefits
• Paid Time Off (PTO) or vacation pay
• Paid holidays throughout the calendar year
• Number of paid holidays, sick time, and other time off provided consistent with relevant state law and company policies

How to Apply

If you're a motivated and compassionate individual with a passion for delivering exceptional customer service and navigating complex medical claims, we invite you to apply for this exciting opportunity. Please submit your application through our website, and we'll be in touch to discuss your qualifications further.

Application Deadline

We anticipate the application window for this opening will close on November 15, 2024. Don't miss out on this exciting role – apply now and take the first step towards a rewarding career with CVS Health! Apply for this job