Bring 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.

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.

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. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 02/01/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.