Senior Claims Specialist
CVS Health
full-time
Posted on:
Location Type: Remote
Location: Kentucky • Louisiana • United States
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Salary
💰 $46,988 - $122,400 per year
Job Level
About the role
- Analyzes and processes insurance claims to ensure complete accuracy, compliance, and timely payment for all patient claims.
- Evaluates the completeness and accuracy of claim forms, supporting documentation, and medical records.
- Determines the reimbursement or payment amounts based on policy coverage, fee schedules, negotiated rates, or other applicable guidelines.
- Ensures compliance with insurance regulations, industry standards, and internal policies when processing claims.
- Investigates and resolves claim denials or rejections by conducting research, consulting policy guidelines, and communicating with relevant parties.
- Analyzes claims data to determine coverage eligibility and compliance with regulatory requirements.
- Generates reports on claims processing metrics and provides insights to improve efficiency, accuracy, and customer satisfaction.
- Provides clear communication with patients to effectively resolve issues and ensure ongoing customer satisfaction.
- Identifies potential fraudulent activities by conducting fraud detection analysis and collaborating with fraud investigation teams.
Requirements
- 3-5 years of experience in medical coding, claims analysis, and healthcare operations.
- Certified Professional Coder (CPC).
- Certified Billing and Coding Specialist (CBCS).
- Previous experience in provider coding.
- Strong time management skills.
- Ability to stay adaptable amidst a fast-paced environment.
- Strong multi-tasking ability.
- Bachelor's degree or equivalent experience (4+ years of relevant experience + high school diploma or GED).
Benefits
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions 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.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical codingclaims analysisclaims processingfraud detection analysisdata analysisreimbursement determinationpolicy compliancereport generationcustomer satisfaction metricsprovider coding
Soft Skills
time managementadaptabilitymulti-taskingcommunicationproblem-solving
Certifications
Certified Professional Coder (CPC)Certified Billing and Coding Specialist (CBCS)