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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.
Position Summary
Aetna Better Health of Oklahoma, a CVS Health company, is a trusted health partner in the local Oklahoma communities we serve. We provide a full array of innovative services that enhance overall wellness and improve everyday life for our members. At Aetna Better Health of Oklahoma, we value professional development and career growth. You will work along other colleagues who align on Heart at Work behaviors and bringing your heart to every moment of health. We will support you all the way!
This is a fulltime teleworker opportunity in Oklahoma. Qualified candidates must reside in Oklahoma.
The Senior Claim Data Specialist handles end-to-end processes associated with claim data management. Identifies and addresses issues impacting auto-adjudication levels and claim accuracy. May complete manual plan-set-up activities related to new business/account implementations.
Fundamental Components:
• 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.
• Makes outbound calls to obtain required information for First claim or re-consideration.
• Reviews and submits requests for Auto Adjudication
• Performs review of submitted projects and results
• Reports financial impact of completed task.
• Looks at trends in data and analyzes that data.
• Works with the claim denial report.
• Must possess advanced Excel skill and the ability to create reports and pivot tables.
• Performs other duties as assigned.
Required Qualifications
- Residency in Oklahoma.
- 1+ years of recent and related healthcare or medical customer service experience.
- 2+ years recent and or related claim processing experience.
- Proficiency in Medicaid and/or Medicare claim platforms and/or products
- Self-starter and ability to work independently.
- 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MC Office Suite Applications (Teams, Outlook, Word, Excel, etc.)
Preferred Qualifications
- QNXT or SQL experience
- Knowledge of Oklahoma Medicaid program
- Excellent written and oral communication skills
- Ability to work collaboratively within work teams
- Ability to manage multiple priorities
- Highly organized and able to quickly prioritize multiple assignments with high quality results
- Ability to interact with different groups of people at different levels
- Detail oriented
- Time management skills
- Analytical skills
- Understanding of medical terminology
- Understanding of medical coding
- Strong knowledge of benefit plans
Education
- High school diploma or equivalent work experience required.
Pay Range
The typical pay range for this role is:
$18.50 – $31.72
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.