Medical Claims Adjuster

2 hours ago

Sacramento, California, United States CVS Health Full time

Job Summary

CVS Health is seeking a skilled Medical Claims Adjustor to join our team. As a Medical Claims Adjustor, 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

  • Perform adjustments across all dollar amount levels on customer service platforms using technical and claims processing expertise.
  • 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.
  • 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 adjustments to claims.
  • May provide job shadowing to lesser-experienced staff.
  • Utilize all resource materials to manage job responsibilities.

Requirements

  • 2+ years of 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.

Preferred Qualifications

  • DG system claims processing experience.
  • Reinsurance/Stop loss medical claims experience.
  • Familiarity with overpayments.

Education

  • Associate degree or equivalent experience.

Pay Range

The typical pay range for this role is $18.50 - $38.82. 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.

CVS Health offers a comprehensive benefits package, including medical, dental, and vision benefits, as well as a 401(k) retirement savings plan and an Employee Stock Purchase Plan. Eligible employees may also participate in a fully-paid term life insurance plan 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, CVS Health employees enjoy Paid Time Off (PTO) or vacation pay, as well as paid holidays throughout the calendar year.

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