Job Description
Job Description
This is permanent work from home position.
* Reviews and adjudicates routine claims in accordance with claim processing guidelines.
* Analyzes and approves routine claims that cannot be auto adjudicated.
* Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
* Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
* Routes and triages complex claims to Senior Claim Benefits Specialist.
* Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
* May facilitate training when considered topic subject matter expert.
* In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor).
* Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).
Required Qualifications
- Experience in a production environment.
- Claim processing experience.
- High School or GED equivalent.
Preferred Qualifications
- Basic computer comprehension skills.
- Ability to type and/or use 10 key.
- Experience in a production based environment.
Education
High school Diploma or GED.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
This is permanent work from home position.
* Reviews and adjudicates routine claims in accordance with claim processing guidelines.
* Analyzes and approves routine claims that cannot be auto adjudicated.
* Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
* Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
* Routes and triages complex claims to Senior Claim Benefits Specialist.
* Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
* May facilitate training when considered topic subject matter expert.
* In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor).
* Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).
Required Qualifications
- Experience in a production environment.
- Claim processing experience.
- High School or GED equivalent.
Preferred Qualifications
- Basic computer comprehension skills.
- Ability to type and/or use 10 key.
- Experience in a production based environment.
Education
High school Diploma or GED.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. 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.
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