At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

• Performs research of complex claim reviews post-adjudication to ensure claims are processed per published policies, procedures and regulatory guidelines. This includes end-to-end claim adjudication and worktask review for legal, regulatory, and audit requests from internal and external customers.
• Will be a key resource in auditing functions for the Medicare and IFP lines of business.
• May perform or assist with special projects, perform analysis of data to identify and communicate quality trends or gaps in policy.
• Consult and/or work cross functionally to influence and promote change in order to continually deliver quality service to our internal and external customers.
• Provides Leadership/Coaching/Mentoring; may be a mentor to others.
• Analyzes complex claims for trends, highlights in-depth interpretations and provides in-depth root cause analysis for claim adjudication. This includes policy, contract, and pricing reviews to ensure correct claim handling.
• Translates complex data into constructive data and information and makes recommendations.
• Illustrates complex information in a clear concise manner.
• Develops and conducts presentations and consultations to existing and prospective customers and internal business areas.
• Provides workgroup support on projects.
• Influences changes/enhancements to business processes, policies, and system infrastructure to improve information quality, availability and access.

Required Qualifications
Medicare Claims Processing Experience/ IFP Claims Processing Experience

Preferred Qualifications
Excellent verbal and written communication skills.  Extensive experience with databases as well interpretation and manipulation of related data. Healthcare background. 3-5 years of data interpretation and analysis experience.

Education

Bachelor's degree, technical certification or equivalent work experience.

• Job Families for Job Profiles

Business Compliance

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$43,888.00 - $102,081.00

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 04/03/2025

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