Full-Time

Medical Claims Negotiator

Updated on 1/17/2025

CVS Health

CVS Health

10,001+ employees

Comprehensive pharmacy and healthcare services

Healthcare
Consumer Goods

Compensation Overview

$47k - $112.2kAnnually

+ Bonus + Commission + Short-term Incentive Program

Senior

Company Historically Provides H1B Sponsorship

Wayzata, MN, USA + 1 more

More locations: Remote in USA

Category
Healthcare Administration & Support
Medical, Clinical & Veterinary
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
  • Bachelor's degree preferred/specialized training/relevant professional qualification.
Responsibilities
  • Investigation of all cases to ensure risk is managed and a proposed rate can be set to begin negotiation process
  • 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.

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, beauty items, and general merchandise. CVS Health also functions as a pharmacy benefits manager, serving over 75 million plan members, and has a senior pharmacy care business that assists more than one million patients each year. This integrated model allows CVS Health to deliver affordable health management solutions, improving access to quality care and health outcomes while aiming to lower overall healthcare costs. Unlike many competitors, CVS Health combines retail pharmacy services with clinical care and pharmacy benefits management, making it a significant player in the healthcare sector with a commitment to enhancing people's health.

Company Stage

Debt Financing

Total Funding

N/A

Headquarters

Woonsocket, Rhode Island

Founded

1963

Simplify Jobs

Simplify's Take

What believers are saying

  • Expansion of telehealth services allows CVS to reach more patients remotely.
  • Increased consumer interest in wellness boosts demand for CVS's health-related products.
  • The trend towards value-based care aligns with CVS's integrated healthcare approach.

What critics are saying

  • Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.
  • The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.
  • The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

What makes CVS Health unique

  • CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.
  • The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.
  • CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

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Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays