Medical Claim Analyst
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Job Description
Medical Claim Analyst reviewing and triaging healthcare claims for CVS Health. Verifying eligibility, preparing authorizations, and resolving payment issues remotely from West Virginia.
Responsibilities:
- Conduct initial review and triage of assigned claims and authorization requests
- Verify member eligibility and benefits coverage
- Identify and redirect misrouted claims or requests to the appropriate department
- Prepare and process authorizations for clinical review by medical staff
- Prioritize workload to meet regulatory requirements and turnaround time standards
- Collaborate with internal and external stakeholders to support medical management activities
- Perform non-clinical research and administrative support functions
- Maintain accurate, complete, and timely documentation in accordance with company, regulatory, and accreditation standards
- Protect the confidentiality of member information and comply with privacy and security policies
- Investigate and assist in resolving claims payment issues
- Support continuous improvement of service quality and member experience
- Serve as a liaison between internal teams, healthcare providers, and external stakeholders to support medical management services and positive member outcomes
Requirements:
- Excellent organizational, time management, and prioritization abilities
- Basic knowledge of medical terminology and healthcare concepts
- Proficiency with Microsoft Office applications, including Excel and Word
- Ability to navigate multiple internal and external computer systems efficiently
- Understanding of benefits administration and management
- Understanding of claims processing and payment management
- Understanding of claims policies and procedures
- Understanding of general business operations
- Understanding of clinical and medical management concepts
- Critical thinking and sound decision-making skills
- 2 to 4 years of experience in a medical assistant role, medical office administration, healthcare claims processing, utilization management, or authorization support preferred
- Experience using CEC, HRP, Rumba, or MedCompass preferred
- High School Diploma or GED required
- Ability to protect confidential member information and comply with privacy and security policies
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility
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