About the Company
CVS Health is a leading healthcare innovation company with a purpose to help people on their path to better health. Through our health services, plans, and community pharmacists, we’re pioneering a ‘community health’ approach to make healthcare more accessible, affordable, and simpler. As a critical player in the health tech sector, we leverage technology to optimize pharmacy benefits management, patient care, and claims processing for millions across the nation.
Job Description
We are seeking a detail-oriented and analytical Remote Pharmacy Claims Analyst to join our dynamic health tech team. This role is crucial for ensuring the accurate and timely processing of pharmacy claims, reviewing denials, identifying trends, and collaborating with various departments to resolve complex issues. The ideal candidate will possess a strong understanding of pharmacy benefits, claims adjudication processes, and regulatory requirements, contributing directly to our mission of delivering seamless healthcare solutions.
Key Responsibilities
- Analyze and process complex pharmacy claims, ensuring accuracy and compliance with plan benefits and regulatory guidelines.
- Investigate and resolve denied claims, identifying root causes and implementing corrective actions.
- Collaborate with pharmacists, healthcare providers, and internal teams to gather necessary information for claims resolution.
- Identify trends in claims processing errors or denials and recommend system enhancements or process improvements.
- Maintain up-to-date knowledge of pharmacy benefit management, coding, and industry regulations (e.g., NCPDP D.0, HIPAA).
- Assist with audits and reporting related to claims data and performance metrics.
- Provide support and guidance on claims-related inquiries to internal and external stakeholders.
- Ensure data integrity and confidentiality in all claims handling processes.
Required Skills
- 2+ years of experience in pharmacy claims processing or a related analytical role.
- Proficiency with pharmacy claims adjudication systems and PBM software.
- Strong analytical and problem-solving skills with meticulous attention to detail.
- Excellent communication skills, both written and verbal, for interacting with diverse stakeholders.
- Ability to work independently in a remote environment while maintaining high productivity.
- Solid understanding of medical terminology, drug names, and pharmacy operations.
- Proficiency in Microsoft Office Suite (Excel, Word, Outlook).
Preferred Qualifications
- Bachelor's degree in Healthcare Administration, Business, or a related field.
- Certified Pharmacy Technician (CPhT) certification.
- Experience with large-scale data analysis and reporting tools.
- Familiarity with various insurance plans and benefit structures (e.g., commercial, Medicare Part D, Medicaid).
Perks & Benefits
- Comprehensive health, dental, and vision insurance plans.
- 401(k) retirement savings plan with company match.
- Paid time off and company holidays.
- Tuition reimbursement program for continued professional development.
- Employee assistance program.
- Work-from-home stipend and equipment.
- Wellness programs and resources.
- Opportunities for career growth and advancement within a leading healthcare company.
How to Apply
If you are interested in this position, please click the "Apply Now" button below. To ensure your application is properly considered, please prepare the following:
- An up-to-date Resume or CV
- A brief cover letter summarizing your experience and motivation
Applications are reviewed on a rolling basis. Only shortlisted candidates will be contacted for an interview.
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