Medical Claim Analyst

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Responsible for initial review and triage of claims tasked for review. Determines coverage, verifies eligibility, identifies and redirects misdirects. Responsible for prepping the authorization in the system and triage cases to medical staff for review. Organized and prioritizes work to meet regulatory and claim turn-around times. Promotes communication, both internally and externally to enhance effectiveness of medical management services and health care team.

Performs non-medical research and support. Adheres to Compliance with PM Policies and Regulatory Standards. Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. Protects the confidentiality of member information and adheres to company policies regarding confidentiality. Assist in the research and resolution of claims payment issue.

• Effective communication, telephonic and organization skills.
• Familiarity with basic medical terminology and concepts used in care.
• Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
• Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.

You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 50 Mbps download and 5 Mbps upload. WiFi and satellite internet are not permitted. A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.

Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live. The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time). If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

• Device & System Navigation:
  Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Communication Tools:
  Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling:
  Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security:
  Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
• Troubleshooting & Support:
  Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Future Growth:
  Openness to learning new skills in…