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Job DescriptionWe have an exciting opportunity for a highly motivated candidate who can effectively and accurately review behavioral health claims, and provide insight into trends. You will be responsible for identifying improvement opportunities by performing root cause analysis and providing input on potential solutions to support behavioral health claim payment more effectively. 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 and legal claim reviews, provider and member escalated complaints, network, and clinical requests for claim assistance. You will be part of a fast-paced environment with tight deadlines requiring individual accountability and strong ownership skills.- Flexible schedule depending on business needs- 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.- Communicate with partnering business areas, such as clinical and network, regarding claim reviews impacting members and providers. - Ownership of ongoing monthly/quarterly proactive reviews based on business needs.- Process/reprocess claims or submit rework project requests for necessary claim remediation.- Research and respond to behavioral health claim questions from business partners. - Process behavioral health claims for escalated member/providers situations and known system gaps supported by claim processing in the department.- Comfortable working with members or providers to resolve escalated claim concerns via email or phone.- Advocate for members by improving timeliness and accuracy of behavioral health claim payments.- Ability to identify error trends through claim reviews and provide insight into possible solutions.Pay RangeThe typical pay range for this role is:Minimum: 43,700Maximum: 100,000Please 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 processing experience 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’ ACAS Medical/Hospital Claim Processing experience- 3-5 years’ experience EPDB- 3-5 years’ experience SCM- 3-5 years’ experience ATV/MedCompass- 3-5 years’ experience Claims/Policies & Procedures - Proven communication skills, both written and verbal- Strong organization skills & time management- Self driven & strong work ethic- Ability to analyze data, translate it into meaningful information and draw conclusions.- Good time management skills.- Ability to manage multiple priorities at the same time.- Ability to work independently with little supervision- Ability to work in a group setting and collaborate with others
Preferred Qualifications
Project Management Skills- Strong Excel Skills/large data files- Self-motivated with the ability to embrace change- Strong problem solving and data analysis skills
EducationHigh School and/or College DegreeBusiness OverviewBring 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. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
Vacancy expired!