This is a work at home opportunity.
We are looking for a medical claims processor who will reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. This individual will handle different types of claims and should progress to a claims subject matter expert who may be asked to assist with training, coaching, and/ or responding to complex issues. May handle customer service inquiries and problems. Reviews pre-specified claims. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Handles 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 against company practices and procedures. Identifies and reports possible claim overpayments, underpayments and any other irregularities. Performs claim re-work calculations.
Experience in a business or production environment.
Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
Ability to maintain accuracy and production standards.
Problem solving and analytical skills. Knowledge and experience in navigating in a Windows environment.
Experience updating information using Excel spreadsheets.
Effective oral and written communication skills.
Knowledge of benefit plans, policies and procedures.
Understanding of medical terminology a plus.
Prior claim processing experience a plus.
Please review required qualifications above
High School diploma, G.E.D. or equivalent experience
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.