Transforming Healthcare through Expertise and Compassion At CVS Health, we're on a mission to redefine the healthcare landscape by making it more personal, convenient, and affordable. As a leader in the industry, we're committed to delivering exceptional services that touch the lives of millions. If you're passionate about making a tangible difference and have a strong background in medical claims adjusting, we invite you to join our team as a Medical Claims Adjustor and be part of a dynamic, fully remote work environment. About CVS Health and Our Culture CVS Health is more than just a company; it's a community driven by a shared purpose: Bringing our heart to every moment of your health. Our Heart At Work Behaviors™ guide our actions and decisions, fostering a culture that values innovation, collaboration, and customer-centricity. We're dedicated to empowering our employees to transform healthcare and make a meaningful impact on the communities we serve. Job Summary As a Medical Claims Adjustor at CVS Health, you will play a critical role in reviewing and adjusting complex medical claims with precision and care. This fully remote position requires a skilled professional with a strong background in medical claims processing and a keen eye for detail. You will be responsible for adjudicating sensitive and specialized claims, handling customer service inquiries, and ensuring compliance with 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, and perform claim re-work calculations as needed. Handle customer service inquiries and problems, utilizing technical and claims processing expertise to resolve issues efficiently. Apply medical necessity guidelines, determine coverage, complete eligibility verification, and identify discrepancies to assist in the claim adjudication process. Follow through on the completion of claim overpayments, underpayments, and any other irregularities, ensuring accuracy and fairness. Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid and allocate refund checks accordingly. Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals with professionalism and empathy. Ensure all compliance requirements are satisfied, and payments are made in accordance with company practices and procedures. Review and handle relevant correspondences assigned to the team that may result in adjustments to claims. Utilize all resource materials to manage job responsibilities effectively and efficiently. May provide job shadowing to lesser experienced staff, sharing knowledge and expertise to foster growth and development. Qualifications and Requirements Essential Qualifications 2+ years of medical claim processing experience, with a strong understanding of claims processing guidelines and procedures. 2+ years of experience in a production environment, demonstrating the ability to work efficiently and accurately under pressure. Associate degree or equivalent experience, providing a solid foundation in a relevant field. Preferred Qualifications DG system claims processing experience, with a proven track record of handling complex claims with ease. Demonstrated ability to handle multiple assignments competently, accurately, and efficiently, showcasing strong organizational and time management skills. Effective communications, organizational, and interpersonal skills, with the ability to work collaboratively with colleagues and engage with customers. Skills and Competencies To succeed as a Medical Claims Adjustor at CVS Health, you will need to possess a unique blend of technical, business, and interpersonal skills. These include: Strong analytical and problem-solving skills, with the ability to interpret complex data and make informed decisions. Excellent communication and customer service skills, with a customer-centric approach and a passion for delivering exceptional service. Ability to work in a fast-paced, dynamic environment, with a focus on productivity and quality. Strong organizational and time management skills, with the ability to prioritize tasks and manage multiple assignments simultaneously. Proficiency in relevant systems and technologies, including claims processing software and other tools. Career Growth and Development At CVS Health, we're committed to helping our employees grow and develop in their careers. As a Medical Claims Adjustor, you will have access to a range of training and development opportunities, including: Comprehensive onboarding program, designed to equip you with the knowledge and skills needed to succeed in your role. Ongoing training and professional development opportunities, to help you stay up-to-date with industry trends and best practices. Career advancement opportunities, with a clear path for progression and growth within the organization. Work Environment and Company Culture As a fully remote employee, you will enjoy the flexibility and autonomy to work from anywhere, while still being connected to a vibrant and supportive community. Our company culture is built on a foundation of inclusivity, diversity, and collaboration, with a focus on: Fostering a culture of innovation and creativity, where employees are encouraged to think outside the box and share their ideas. Promoting work-life balance, with a range of benefits and programs designed to support employees' physical, emotional, and mental well-being. Celebrating diversity and inclusion, with a commitment to creating a workplace that is welcoming and inclusive for all employees. Compensation and Benefits We offer a competitive compensation package, with a pay range of $18.50 - $35.29 per hour, depending on experience and qualifications. In addition to your base salary, you will be eligible for a range of benefits, including: Comprehensive medical, dental, and vision benefits, to support your physical and mental health. 401(k) retirement savings plan, with a company match to help you plan for your future. Employee Stock Purchase Plan, to give you a stake in the company's success. Term life insurance, short-term and long-term disability benefits, to provide financial protection and security. Paid Time Off (PTO) and holidays, to give you time to rest and recharge. Well-being programs, education assistance, and other benefits to support your overall well-being. Join Our Team If you're a motivated and experienced Medical Claims Adjustor looking for a new challenge, we encourage you to apply for this exciting opportunity. At CVS Health, we're passionate about making a difference in the lives of our customers, and we're looking for talented professionals to join our team. Don't hesitate – apply today and take the first step towards a rewarding and fulfilling career with CVS Health! We anticipate the application window for this opening will close on November 15, 2024. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws. Apply for this job