Senior Claim Data Specialist (Must reside in Oklahoma)

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.Position Summary

Aetna Better Health of Oklahoma, a CVS Health company, is a trusted health partner in the local Oklahoma communities we serve. We provide a full array of innovative services that enhance overall wellness and improve everyday life for our members. At Aetna Better Health of Oklahoma, we value professional development and career growth. You will work along other colleagues who align on Heart at Work behaviors and bringing your heart to every moment of health. We will support you all the way!This is a fulltime teleworker opportunity in Oklahoma.The Senior Claim Data Specialist handles end-to-end processes associated with claim data management. This person identifies and addresses issues impacting auto-adjudication levels and claim accuracy. They may also complete manual plan-set-up activities related to new business/account implementations.

• Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
• Handles phone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.
• Identifies and reports possible claim overpayments, underpayments and any other irregularities.
• Performs claim re-work calculations.
• Makes outbound calls to obtain required information for first claim or re-consideration.
• Reviews and submits requests for Auto Adjudication.
• Performs review of submitted projects and results, reports financial impact of completed task, views and analyzes trends in data, and works with the claim denial report.
• Performs other duties as assigned.

• 1+ years of experience in healthcare and/or medical customer service.
• 2+ years of experience in claim processing, including a proficiency in Medicaid and/or Medicare claim platforms and/or products.
• 2+ years of experience using personal computer, keyboard navigation, navigating multiple systems and applications, and using Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.). Must possess advanced Excel skills and the ability to create reports and pivot tables.
• Ability to travel up to 10% of time, primarily to Oklahoma City office.

• Previous experience with commercial insurance.
• Self-starter and ability to work independently.
• QNXT or SQL experience
• Knowledge of Oklahoma Medicaid program.
• Excellent written and oral communication skills.
• Ability to work collaboratively within work teams.
• Ability to manage multiple priorities.
• Highly organized and able to quickly prioritize multiple assignments with high quality results.
• Ability to interact with different groups of people at different levels.
• Detail-oriented.
• Time management skills.
• Analytical skills.
• Understanding of medical terminology.
• Understanding of medical coding.
• Strong knowledge of benefit plans.

• High school diploma or GED.

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• 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.