Sr Claim Data Specialist
Sr Claim Data Specialist
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Job Description
At CVS Health were building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nations leading health solutions company we reach millions of Americans through our local presence digital channels and more than 300000 purposedriven 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
Performs detailed review and analysis of Medicare Supplement claims. Verifies claim validity and ensures accurate and timely processing. Identifies potential fraud waste and abuse through data analysis and claims review.
Performs indepth data analysis to detect patterns or anomalies indicative of potential fraud waste and abuse.
Escalates suspicious billing behavior or inconsistent patterns to management or the Special Investigations Unit (SIU) providing supporting documentation and analysis.
Monitors claim trends and highlight FWA risks related to Med Supp processing.
Identifies system and process improvements in workflows to enhance accuracy timeliness and fraud prevention.
Provides mentorship and technical guidance to junior team members regarding Med Supp processes FWA detection techniques and data quality best practices.
Partners with Compliance SIU and Claims Operations to support the development and implementation of FWA strategies and training initiatives.
Required Qualifications
3 years of experience in claims processing or data analysis including Medicare Supplement claims
Strong problemsolving and decisionmaking skills with a focus on compliance and FWA detection
Proficiency in analyzing claims data and reporting tools (Excel SQL Tableau etc.
Preferred Qualifications
Familiarity with CMS guidelines coordination of benefits processes and FWA red flags
Education
High school diploma or equivalent required
College coursework or certification in health information management fraud investigation or medical billing preferred
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$18.50 $35.29This pay range represents the base hourly rate or base annual fulltime 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 shortterm 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:
Affordable medical plan options a 401(k) plan (including matching company contributions) and an employee stock purchase plan.
Nocost 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.
For more information visit anticipate the application window for this opening will close on: 05/27/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal state and local laws.
Required Experience:
Senior IC
Employment Type
Full-Time
