Medical Claims Adjustor

. Process provider refunds and returned checks. May handle customer service inquiries and problems.

• Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise.

• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.

• Performs 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.

• Ensures 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.

Required Qualifications

• 2+ years medical claims processing experience.

• Experience in a production environment.

• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.

• Effective communications, organizational, and interpersonal skills

Preferred Qualifications

• DG system claims processing experience.

• Reinsurance / Stop loss medical claims experience.

• Familiarity with overpayments.

Education

• Associate degree or equivalent experience.

Pay Range

The typical pay range for this role is:

$18.50 - $38.82

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.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 10/25/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.