Medical Claim Analyst

Job DescriptionCCR is responsible for post - service claim review to determine if specific services can be reimbursed to providers and members.- The analyst role is integral to the CCR team.-They start the CCR process with the claim submission to CCR with a complete review of the claim and claim history. They compile all system information, claim history, plan information, and any additional research into template asrequired by the workflow and any legal and regulatory requirements for aclinician review.-They also collaborate with Medical Directors as required.-Review provider and member claims to determine if they meet CCR reviewrequirements.-Follow applicable workflows, templates, and legal and compliancerequirements to provide a complete picture of what is requiring review to theCCR clinicians and medical directors.-Organizes and prioritizes work to help meet regulatory and CCR claim turn around times.-Determines coverage, verifies eligibility, benefits, identifies discrepancies and applies all Medical Claim Management policies and procedures to assist in ensuring claims are handled per policy and legal requirements.-Works with all appropriate internal and external departments and personnel to accurately review specified claims and/or clarify any issues found in the course of the review.-Required to work in multiple systems including EWM, ASD, ATV, MedCompass and HRP.-Other systems dependent on specific reviews criteria.-Maintains and utilizes all resource materials and systems to effectively manage job responsibilities.-Adheres to company policies to protect memberconfidentiality.Pay RangeThe typical pay range for this role is:Minimum: 18.50Maximum: 34.60Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required QualificationsDemonstrated ability to handle multiple assignments competently, accurately and efficiently.Preferred Qualifications-Knowledge of utilization management rules and regulations and claim processing guidelines-Customer service experience preferred.-2+ years claim processing experienceEducationVerifiable High School Diploma or GED.Business OverviewBring your heart to CVS Health Every 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. 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.

Created: 2025-11-15