[Hiring] Claims Processing - Representative I @CVS Health

Role Description

Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. Additional responsibilities include:

• Receives and monitors the completeness and accuracy of claims forms and supporting documentation submitted by healthcare providers.
• Enters claim information, such as patient information, provider details, procedure codes, and diagnosis codes, into the company's claims processing system.
• Documents relevant information for the eligibility of the claim, determining coverage and benefits, and assessing the validity and medical necessity of the services rendered.
• Calculates claim payments based on the approved reimbursement rates, fee schedules, or contracted rates with healthcare providers.
• Communicates claim status updates to healthcare providers, policyholders, or other stakeholders to provide transparency and ensure any additional information is resolved quickly.
• Assists in resolving discrepancies or issues related to claims by researching and investigating claim-related inquiries, collaborating with internal teams or departments, and coordinating with healthcare providers to resolve claim processing errors or discrepancies.
• Provides customer service support by addressing inquiries and resolving issues related to claims processing.
• Ensures that all claims processing details and notes are inputted into the company systems database.
• Assists in data entry tasks related to claims data management, such as updating claim statuses, maintaining accurate records, or ensuring proper documentation of claims processing activities.

Qualifications

• 1 year work experience in Customer Service/ Data Entry in Healthcare
• Experience using Microsoft Office Suite (Outlook, Teams, Word, etc.)
• Working knowledge of problem solving and decision making skills

Requirements

• Certified Billing and Coding Specialist (CBCS) preferred.
• Intermediate experience using Microsoft Excel

Education

• High School Diploma or equivalent GED

Anticipated Weekly Hours

• 40

Time Type

• Full time

Pay Range

The typical pay range for this role is: $17.00 - $28.46. 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.

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• 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.