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.

　　Candidates must reside in MI, 3 days in office and 2 days home.

　　Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems. Reviews pre-specified claims or claims that exceed processing expertise.

　　Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.

　　Handles phone and written inquiries related to requests for reconsiderations and appeals.

　　Responsibilities Include:

　　-Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.

　　-Identifies and reports possible claim overpayments, underpayments, and any other irregularities.

　　-Performs claim re-work calculations.

　　-Distributes work assignments daily to junior staff and Trains and mentors claim benefit specialists.

　　-Makes outbound calls to obtain required information for First claim or re-consideration.

　　-Trained and equipped to support call center activity if required, including general member inquiries.

　　- Reviewing pre-specified claims or claims that exceed processing expertise.

　　- Applying medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.

　　- Handling phone and written inquiries related to requests for reconsiderations and appeals.

　　- Ensuring all compliance requirements are satisfied and that all payments are made against company practices and procedures.

　　- Identifying and reports possible claim overpayments, underpayments, and any other irregularities.

　　- Performing claim re-work calculations.

　　- Distributing work assignments daily to junior staff.

　　- Training and mentoring claim benefit specialists.

　　- Making outbound calls to obtain required information for First claim or re-consideration.

　　Requirement:

　　- Trained and equipped to support call center activity if required, including general member inquiries.- 2+ years claim processing experience.

　　- Claim processing experience. Experience in a production environment.

　　- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

　　- Meritian Claims knowledge a PLUS

　　- Great communication skills, able to support escalations.

　　Education:

　　Associate's degree or equivalent work experience.

　　Pay Range

　　The typical pay range for this role is:

　　$18.50 - $34.60

　　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.

　　In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

　　For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

　　CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

　　You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

　　CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through [email protected] If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.