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 specialist adjudication authority or 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 pre-approvals/pre-authorizations, reconsiderations, or appeals.
-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.
-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 and/or provider inquiries.
-Experience in a production environment.
-Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
-2+ years claim processing experience.
-Claim processing experience.
-Associate's degree or equivalent work experience.
-DG system claims processing experience is required.
Please review required qualifications above.
Associate's degree or equivalent experience.
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. 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.
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