Position Summary: As the Claims Surveillance Senior Advisor you will have the overall responsibility for the accuracy of claims through research and validation for all lines of business(Medicaid/Commercial/Exchanges). You will focus on driving claim results and reports that will improve our ability to deliver high quality benefit plans in a timely manner to the marketplace. This includes the strategy,managing timelines and key deliverables as well as the quality control process(Audit) necessary to ensure benefits are set up accurately pre- and post-go live. You will be responsible for the overall communication to leadership on the status including tracking and reporting for all lines of business.
As the Claims Surveillance Senior Advisor you’ll also be involved in proactive testing, planning, effective communication, coordination and project management of select organizational initiatives, action tracking and follow-up, and coordinating benefit automation projects in support of the Business Unit.
You will be responsible for ensuring organizational processes are optimally aligned and coordinated between and among groups and projects. Focus areas include: quality improvement, procedures, and workflow management.
Responsibilities of the position include daily operational oversight, support and analyze requests from the BI team, translate client requirements into requirements for BI team to create rules for monitoring, training & documentation.
You'll be reviewing claims and determining anomalies,tracking, reporting, following up with cross team members on status. Additionally, there will be enhanced reporting and review of claims surveillance activities during the first 15 days of each month, with increased focus on the beginning and middle of the year. You will work with internal partners, peers and staff to ensure all work is done accurately and on time.
As a Claims Surveillance Senior Advisor, you will be responsible for reviewing claims from complex client plan designs within the adjudication support system, driving automation and providing tactical and strategic directions for Claim surveillance road map. In this role you will also mentor the junior level and consultants to ensure a successful Welcome Season and for all maintenance of business activities for new and existing clients.
You’ll accomplish this by:
- Leading the way for RxClaim interpretation,analysis, and knowledge transfer to further strengthen claims surveillance activities.
- Building and maintaining relationships with test centers of excellence, benefit coding teams and account management teams.
- Analyzing, interpreting and comprehending complex client benefits requirements, commitments and contracts.
As a Senior Sdvisor, your success will be driven by exceeding client satisfaction score targets as well as contributing to reduced service warranty payments to clients. Your healthcare industry knowledge, RXClaim/AS400 Coding experience and process improvement skills is critical to your success. You will operate in a fast-paced environment with tight deadlines so ability to operate autonomously and make key decisions is imperative. The contributions you will make will position CVS Health as a leader in client satisfaction and service in the PBM marketplace.
Required Qualifications: * 4+ years of healthcare claims research, including benefit coding experience in AS400/RxClaim
* 6+ years of demonstrated experience leading healthcare related benefits projects
Preferred Qualifications: * Advanced Microsoft Excel skills for data analysis and Macro development; Proficient is using other Microsoft Office applications including PowerPoint.
Education: * Bachelor's degree is required; equivalent work experience may substitute
CVS Health, through our unmatched breadth of service offerings, is transforming the delivery of health care services in the U.S. We are an innovative, fast-growing company guided by values that focus on teamwork, integrity and respect for our colleagues and customers. What are we looking for in our colleagues? We seek fresh ideas, new perspectives, a diversity of experiences, and a dedication to service that will help us better meet the needs of the many people and businesses that rely on us each day. As the nation’s largest pharmacy health care provider, we offer a wide range of exciting and fulfilling career opportunities across our three business units – MinuteClinic, pharmacy benefit management (PBM) and retail pharmacy. Our energetic and service-oriented colleagues work hard every day to make a positive difference in the lives of our customers.
CVS Health is an equal opportunity employer. We do not discriminate in hiring or employment against any individual on the basis of race, ethnicity, ancestry, color, religion, sex/gender (including pregnancy), national origin, sexual orientation, gender identity or expression, physical or mental disability, medical condition, age, veteran status, military status, marital status, genetic information, citizenship status, unemployment status, political affiliation, or on any other basis or characteristic prohibited by applicable federal, state or local law. CVS Health will consider qualified job candidates with criminal histories in a manner consistent with federal, state and local laws. CVS Health will not discharge or in any other manner discriminate against any Colleague or applicant for employment because such Colleague or applicant has inquired about, discussed, or disclosed the compensation of the Colleague or applicant or another Colleague or applicant. Furthermore, we comply with the laws and regulations set forth in the following EEO is the Law Poster: EEO IS THE LAW
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