Sr Claims Provider Analyst

Job DescriptionHandles 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 associated with new business/account implementations.Performs as Subject Matter Expert for the team relative to complex set-up, processing, system, policies and/or department workflows, meeting internal/external deadlines for production and quality of various products and services.Analyzes and determines if products and services selected by customers are aligned with their benefit needs, and can be adequately supported through existing systems or operating platforms; alternately, seeks solutions and negotiate essential requirements in support of any non-standard plan selections.Presents information effectively to various levels of employees and management through various formats, i.e. one on one, staff/customer meetings, presentations, etc.Provides supervisory back up and assists in the delegation of issues and proposes streamlined workload assignments.Leads process improvement initiatives to improve productivity, accuracy and/or customer service and tool development. Manages assigned projects and ensures project plans and/or work tasks align with overall organizational goals.Assists with the development and testing of new or enhanced product offerings as assigned. Mentors other employees associated with claim data management (e.g. provides technical expertise to team/unit).Assists with the development, delivery and implementation of training tools and processes.May be responsible for training staff on transplant claim processing and the administration of the Institutes of Excellence (IOE) contracts and Letters of Agreement (LOA) for accurate review and application of the negotiated rates for these claims. Exhibits behaviors outlined in Claim Data Specialist CompetenciesRequired QualificationsMinimum of one year of recent and related direct CLAIMS experience.Minimum of three years of recent and related ACAS Plan Setup Experience.Minimum one year of recent and related Aetna claim processing experience.Proficiency in all claim platforms and/or products, i.e. Traditional, HMO, Medicaid, HNO High school diploma or equivalent work experience termediate/advanced excel Certified Professional Coder (CPC) PreferredCOVID RequirementsCOVID-19 Vaccination RequirementCVS 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.Preferred QualificationsMinimum of one year of recent and related direct CLAIMS experience.Minimum of three years of recent and related ACAS Plan Setup Experience.Minimum one year of recent and related Aetna claim processing experience.Proficiency in all claim platforms and/or products, i.e. Traditional, HMO, Medicaid, HNO High school diploma or equivalent work experience termediate/advanced excel Certified Professional Coder (CPC) PreferredEducationEducation : High School diploma, G.E.D. or equivalent experienceBusiness OverviewBring your heart to CVS HealthEvery 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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-09-06