This position is a work from home position in any time zone.

• Reviews and adjudicates routine claims in accordance with claim processing guidelines.
• Analyzes and approves routine claims that cannot be auto adjudicated.
• Applies medical necessity guidelines, determines coverage, complete eligibly verification, identify discrepancies and applies all cost containment measures to assist in the claim adjudication process.
• Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
• Routes and triages complex claims to Senior Claim Benefits Specialist.
• Proofs claim or referral submission to determine, review or apply appropriate guidelines, coding, member identification process, diagnosis and pre-coding requirements.
• May facilitate training when considered topic subject matter expert.
• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic correspondence Handling System - system used to process correspondence that is scanned in the system by a vendor).
• Utilizes all applicable system functions available ensuring accurate and timely claim processing services (i.e. utilizes claim check, reasonable and customary data, and other post-containment tools).

Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.90

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications
This position is a work from home position in any time zone.

• Reviews and adjudicates routine claims in accordance with claim processing guidelines.
• Analyzes and approves routine claims that cannot be auto adjudicated.
• Applies medical necessity guidelines, determines coverage, complete eligibly verification, identify discrepancies and applies all cost containment measures to assist in the claim adjudication process.
• Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
• Routes and triages complex claims to Senior Claim Benefits Specialist.
• Proofs claim or referral submission to determine, review or apply appropriate guidelines, coding, member identification process, diagnosis and pre-coding requirements.
• May facilitate training when considered topic subject matter expert.
• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic correspondence Handling System - system used to process correspondence that is scanned in the system by a vendor).
• Utilizes all applicable system functions available ensuring accurate and timely claim processing services (i.e. utilizes claim check, reasonable and customary data, and other post-containment tools).

Preferred Qualifications
Medicaid
Qnxt
Medical Coding

Education
High School diploma or GED equivalent

Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. 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.