Medical Claim Analyst

About CVS Health

At CVS Health®, we strive to create a healthier world by enhancing the health experience for individuals, families, and communities. Our environment is fueled by passionate colleagues dedicated to innovation, accountability, safety, and quality.

Position Summary

The Medical Claim Analyst becomes an integral part of the Provider Coding and Reimbursement (PCR) team, focusing on reviewing provider coding and handling reimbursement denial disputes submitted by providers.

Key Responsibilities

• Evaluate provider resubmissions related to ClaimsXten, Clinical Validation, Prospective Claim Accuracy, Novologix, and DRG claims, resolving or preparing them for review by an Aetna clinician.
• Manage workload efficiently by prioritizing tasks and multitasking to meet deadlines.
• Review provider rework claims aligning with claim processing and PCR directives.
• Conduct research of claims using ASD or ACAS/EWM systems.
• Document claim histories accurately in the Aetna Strategic Desktop (ASD) and Electronic Correspondence Handling System (ECHS).

Requirements

• Thorough understanding of the Aetna ACAS claims platform with at least one year of hands-on ACAS claim processing experience.
• Capability to analyze and assess claims effectively.
• Experience with rework processes and familiarity with EWM, ASD, and ECHS.
• Knowledge of system functionalities including IFP, HRP, supporting exchanges.
• Proficiency in using Excel spreadsheets as required.
• Strong communication and teamwork abilities within Aetna and cross-departmentally.
• Ability to work autonomously and collaboratively.
• Competency in balancing multiple projects to meet productivity and quality benchmarks.

Preferred Qualifications

• Advanced experience with ACAS/EWM systems is strongly preferred.
• Prior claims processing experience advantageous.
• Consistent record of high-quality outcomes with deep claim knowledge.
• Good analytical aptitude and strong technical skills.
• In-depth understanding of benefit plans, policies, and procedures.
• Proven ability to effectively manage multiple tasks with accuracy and efficiency.
• Exceptional attention to detail.

Education

High School diploma, GED, or equivalent work experience is required.

Working Hours & Pay

This is a full-time position with an anticipated 40 hours per week schedule.

Compensation ranges from $18.50 to $35.29 per hour, varying based on experience, education, location, and other factors.

Benefits

This full-time role qualifies for a comprehensive benefits package supporting the physical, emotional, and financial well-being of employees and their families, which includes medical, dental, vision coverage, paid time off, retirement savings options, and wellness programs.

Diversity & Inclusion

CVS Health values a diverse workforce reflecting the customers and communities it serves and is committed to creating an inclusive workplace where every colleague feels valued and belongs.

Legal Considerations

Applicants with criminal histories will be evaluated in compliance with applicable federal, state, and local laws.