CVS Health | REMOTE: Senior Analyst – Business Claim Analytics | Tampa, FL | United States | BigDataKB.com | 2022/10/30

We are looking for a highly motivated candidate who can effectively and accurately review behavioral health claims, identify inaccuracies, perform root cause analysis, and provide input on potential solutions. The candidate will be required to process/reprocess claims or submit rework projects as needed. You will work closely with business partners providing review updates, root cause analysis summary, solutioning and detailed resolution of affected claims. The candidate is responsible for ensuring claim reviews stay on track and are resolved accurately by the specified due date.

The candidate will serve as the lead for various claim and benefit reviews such as compliance claim reviews, provider and member escalated complaints, network, and clinical requests for claim assistance.

• Maintain a specialized knowledge of Behavioral Health claim processing and policy impacts.
• Support business partners in discussions specific behavioral health claim handling.
• Create claim testing scenario, perform testing in ACASPBTE and provide confirmation the system is functioning as expected.
• Ownership of reviewing and requesting updates to Behavioral Health claim and call policies to improve clarity of details.
• Communicate with partnering business areas, such as clinical and network, regarding claim reviews impacting members and providers.
• Research and respond to behavioral health claim questions from various business areas.
• Process behavioral health claims for escalated member/providers situations and known system gaps supported by claim processing in the department.

Pay Range
The typical pay range for this role is:
Minimum: 43,700
Maximum: 97,400

Please 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 Qualifications

• The candidate MUST HAVE knowledge of ACAS claim system and will be responsible for regular project discussion/updates via conference calls.
• Candidate MUST HAVE knowledge of Aetna’s Commercial Products.
• 3-5 years’ experience within the ACAS platform
• 3-5 years’ experience with claim adjudication
• 3-5 years’ experience EPDB
• 3-5 years’ experience SCM
• 3-5 years’ experience Claims/Policies & Procedures

Preferred Qualifications

• Team player who is organized and able to manage multiple priorities.
• Strong organization skills & time management
• Proven communication skills, both written and verbal
• Self driven & strong work ethic
• Ability to analyze data, translate it into meaningful information and draw conclusions.
• Ability to manage multiple priorities at the same time.
• Ability to work independently as well as part of the team.

Education
High School and/or College Degree

Business Overview
Bring 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.