Job Category: Business Analyst Clinical Licensure Required : N/A Job Type: Full Time Position Summary: Responsible to review & interpret claims data in all adjudication platforms. Perform complex reviews/audits of claim adjustments/recoveries/reconciliations for Medicare Part D plans. Analyze the accuracy of participant's accumulations and financial adjustments. Validate the execution of proper controls/procedures. Work with internal and external partners to resolve Coordination Of Benefits related issues by developing new processes and procedures ensuring that beneficiaries, providers and clients are made financially whole. Work with CMS, federal and states agencies in COB related efforts to ensure proper reimbursement to primary and or secondary payers. Responsible for meeting or exceeding turnaround time standards and quality expectations. Communicate effectively; express thoughts in a clear, concise manner in both individual and group situations.
Essential Job Functions: -Work with CMS, federal and states agencies in COB related efforts to ensure proper reimbursement to primary and or secondary payers. -Effectively plan, prioritize, organize time and workload -Effectively present information and respond to questions from internal and external personnel. -Accurately research and adjudicate claims in order to arrive at expected outcome -Perform complex reviews/audits of claim adjustments/recoveries/reconciliations for Medicare Part D plans -Work with internal and external partners to resolve Coordination Of Benefits related issues by developing new processes and procedures ensuring that beneficiaries, providers and clients are made financially whole.
Required Qualifications: -Excellent written and verbal communication skills -Well organized with the ability to effectively handle multiple priorities - Ownership and results driven - Attention to detail - Able to handle high volume receipts within defined turnaround times coupled with excellent quality - Expert proficiency in Microsoft Office Excel - Working knowledge of accounting principles - Ability to effectively work within a team - Flexible in adapting to change - Demonstrated ability to analyze data and determine conclusions - Ability to learn and apply increasingly complex concepts, policies and procedures - Ability to effectively plan, prioritize, organize time and workload - Ability to work successfully in a deadline-oriented environment Preferred Qualifications: 3+ years relevant experience. Previous Coordination of Benefits/Medicare Secondary Payer Experience, Pharmacy, Healthcare preferred Education: Bachelor's Degree or equivalent work experience required Business Overview: CVS Caremark, 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 nations largest pharmacy health care provider, we offer a wide range of exciting and fulfilling career opportunities across our three business units Minute Clinic, 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. turnaround BETS_ARC_Setter BACH_6df36a in times research personnel