Medical Claims Adjuster
4 weeks ago
We are seeking a skilled Medical Claims Adjuster to join our team at CVS Health. As a Medical Claims Adjuster, you will be responsible for reviewing and adjusting SF, FI, Reinsurance, and/or RX claims, as well as adjudicating complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.
Key Responsibilities- Review and adjust claims to ensure accuracy and compliance with company policies and procedures
- Adjudicate complex claims, including those involving medical necessity, coverage, and cost containment measures
- Process provider refunds and returned checks, as well as handle customer service inquiries and problems
- Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
- Perform claim re-work calculations and follow through on completion of claim overpayments, underpayments, and any other irregularities
- Process complex non-routine Provider Refunds and Returned Checks
- Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid and allocate refund checks
- Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals
- Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures
- Review and handle relevant correspondences assigned to the team that may result in adjustment to claims
- May provide job shadowing to lesser experience staff
- Utilize all resource materials to manage job responsibilities
- 2+ years medical claims processing experience
- Experience in a production environment
- Demonstrated ability to handle multiple assignments competently, accurately, and efficiently
- Effective communications, organizational, and interpersonal skills
- DG system claims processing experience
- Reinsurance / Stop loss medical claims experience
- Familiarity with overpayments
- Associate degree or equivalent experience
We offer a competitive salary, comprehensive benefits package, and opportunities for professional growth and development. If you are a motivated and detail-oriented individual with a passion for healthcare, we encourage you to apply for this exciting opportunity to join our team at CVS Health.
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