Medical Claims Negotiator
- Full-Time
At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Virtual Assistant, $45/hr, Remote, No Experience, Night Job
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Live Chat Support, $40/hr, Remote, Entry Level, Part-Time
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Remote Data Entry, $45/hr, No Degree, Night Shift
Part-Time Customer Support, $40/hr, Remote, College Student
Remote Live Chat, $50/hr, Part-Time, Evening/Night Job
Weekend Data Entry, $45/hr, Remote, No Experience
Remote Virtual Assistant, $40/hr, Evening, Part-Time Job
Remote Moderator, $42/hr, Part-Time, Weekend, No Degree
Data Entry, $45/hr, Remote, Night Shift, College Student Job
Phone Support, Remote, $50/hr, No Experience, Part-Time
Virtual Assistant, No Experience, $42/hr, Remote, Weekend
Remote Customer Support, $45/hr, Part-Time, College Student
Data Entry, Remote, $40/hr, Night Shift, No Degree
Evening Virtual Assistant, Remote, $45/hr, No Experience
Weekend Customer Support, $42/hr, Remote, College Student
Remote Data Entry, $50/hr, No Experience, Evening/Night Job
Remote Live Chat, $40/hr, Part-Time, No Degree Required
Virtual Assistant, $42/hr, Remote, Weekend, Entry Level
Remote Phone Support, $45/hr, Evening, No Experience Required
Data Entry, No Experience, $50/hr, Remote, College Student
Remote Moderator, $40/hr, Weekend, No Degree, Part-Time
Live Chat Support, Remote, $42/hr, Night Shift, College Student
Phone Job, $50/hr, Remote, No Degree, Part-Time, Weekend
Data Entry, $45/hr, Remote, Evening, No Experience Required
Virtual Assistant, No Experience, $42/hr, Remote, Part-Time
Remote Customer Support, $50/hr, Night Shift, No Degree
Remote Data Entry, $40/hr, College Student Friendly, Part-Time
Live Chat Support, $42/hr, Weekend, Remote, No Degree
Virtual Assistant, Remote, $45/hr, Evening, No Experience
Remote Phone Job, $50/hr, College Student, Night Shift
Remote Moderator, $42/hr, Weekend, No Experience Required
Data Entry, No Degree, $45/hr, Part-Time, Remote Job
Customer Support, $50/hr, Remote, Evening/Night Job, No Degree
Virtual Assistant, $42/hr, Remote, Weekend, No Degree
Remote Live Chat, $45/hr, College Student, No Experience
Remote Data Entry, $40/hr, Part-Time, No Degree Required
Phone Support, $50/hr, Weekend, Remote, No Experience
Virtual Assistant, $42/hr, Evening, Remote, No Degree
Remote Customer Support, $45/hr, No Experience, Part-Time
Data Entry, $50/hr, Night Job, No Degree, Remote
Remote Moderator, $40/hr, College Student Friendly, Part-Time
Virtual Assistant, Remote, $42/hr, Weekend, No Experience
A Brief Overview
To evaluate, negotiate, and document, Out-Of-Network medical services/supplies/drugs utilizing industry standards to support defensible and reproducible outcomes in managing our clients' health care dollars. Due to the variety of clinical conditions being managed, ongoing training is required for the medical economics of the cases being worked up to support defensible outcomes; many cases have high visibility and potential risk. The role is pivotal in support high risk, high cost, and potentially, high visibility cases, requiring attention to detail and an emphasis on accuracy.
Responsibilities:
Investigation of all cases to ensure risk is managed and a proposed rate can be set to begin negotiation process, to include but not limited to, reviewing clinical picture, benchmarking value of service/supply/drug (manual calculation of U&C), provider contact information, evaluating stop loss implications, confirmation of network status of provider, other insurance, subrogation, claim edits, coding conflicts, reporting of units, cost, consulting with leadership on complex, high dollar cases, and drafting documentation supporting all investigatory sources; drafting summaries on escalated cases working with Meritain as needed to support cases requiring such needs as benchmarking (FCR), claim examiner support, other insurance, medical necessity, corrected claims, change in medical review or eligible services, rework, referring cases to Special Investigation unit, to stop loss carrier coordinator, to client management team, and networking to handle all cases.
For this role you will need Minimum Requirements:
5-8 years in a medical claim's environment with emphasis on edits, Centers for Medicare and Medicaid Services (CMS) standards, calculating accurate U&C, benchmarking medical costs, negotiating, setting up fee schedules, understanding Stop Loss risks, or a mixture of these attributes to support cost management on behalf of our clients; management of phone calls and working with complex subject matter.
Education
Bachelor's degree preferred/specialized training/relevant professional qualification.
Anticipated Weekly Hours
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
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Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
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No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
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Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
