Job Description: Perform initial review and triage of claims tasked for review Determine coverage and verify eligibility Identify and redirect misdirected claims Prepare authorizations in the system Triage cases to medical staff for review Organize and prioritize work to meet regulatory and claim turnaround times Promote internal and external communication to enhance medical management services and healthcare team effectiveness Perform non-medical research and support Adhere to PM policies, compliance requirements, and regulatory standards Maintain accurate and complete documentation meeting risk management, regulatory, and accreditation requirements Protect member information confidentiality Research and resolve claims payment issues Requirements: Effective communication, telephonic, and organization skills Familiarity with basic medical terminology and concepts used in care Strong customer service skills Attention to customers and sensitivity to issues Proactive identification and resolution of issues Computer literacy, including navigating internal and external computer systems Excel and Microsoft Word proficiency High School Diploma or G.E.D 2–4 years of experience as a medical assistant, office assistant, or claim processor (preferred) Familiarity with CEC/GPS or MedCompass (preferred) Benefits: CVS Health bonus, commission or short-term incentive program in addition to base pay Medical coverage Dental coverage Vision coverage Paid time off Retirement savings options Wellness programs Other resources supporting colleagues’ and families’ physical, emotional, and financial well-being
