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.
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
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$46,988.00 - $112,200.00
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.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 03/28/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
We are an equal opportunity and affirmative action employer. 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.
