Claim Field Analyst (Tampa/Orlando, Florida) at CVS Health

Pineville, Kentucky, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

3+ years of experience in medical billing and coding, specifically related to claims processing and root cause analysis
3+ years of experience with provider engagement/relations
Working proficiency of Microsoft Office products (Word, Excel, PowerPoint, Outlook)
Advanced experience in Microsoft Excel for data mining
Must reside in Central Florida - Tampa (Region D - Hardee, Highlands, Hillsborough, Manatee, Polk) and/or Orlando (Region E - Brevard, Orange, Osceola, Seminole)
Ability to travel 70% of time within Central Florida and will work remotely the remaining 30% of the time
Ability to work Monday-Friday from 8am-5pm EST, with the flexibility to work beyond core hours as needed
High school diploma or GED

Responsibilities

Act as the primary resource for groups and providers within a specific geographic location to establish, oversee, and maintain a proactive claim education program focused on assisting providers with claim denials, claim education, and claim resolution
Analyze claim denials to track and trend potential opportunities to assist in training and education of participating and non-participating providers
Assist in creating bulletins, newsletters, and claim trainings to improve provider claims issues and billing practices
Collaborate with internal and/or external departments to identify claim training and education opportunities
Develop, implement, support, and promote provider training strategies, tactics, policies, and programs that drive provider satisfaction specific to claim submission and payments
Work with the grievance and appeal and claims operations department to trend provider claim issues or concerns that could be prevented with additional provider claim education
Work with the provider engagement team to collaborate on provider education when additional detailed claim education is needed
Meet regularly, both in person and virtually, with assigned providers to conduct trainings and educations, review claim trends, and ensure understanding of Aetna Medicaid claim and billing policies and procedures (expected to spend 70% of time meeting with providers in-person, plus occasional telephonic or virtual meetings)
Respond to assigned provider claim questions or inquiries, and if necessary, ensure prompt resolution to provider issues with appropriate enterprise business teams
Other duties as assigned

Skills

Claim Analysis

Claim Denials

Provider Education

Data Trending

Training Development

Billing Practices

Grievance Handling

Appeals Processing

Provider Relations

Claim Resolution

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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