Woonsocket, Rhode island
RXClaim Guru Job Opening in Woonsocket, Rhode island - As the Claims Surveillance Senior Advisor you will have the overall responsibility for the accuracy of claims through research and validation for all lines of business().
You will focus on driving claim results and reports that will improve our ability to deliver high quality benefit plans in a timely manner to the marketplace.
This includes the strategy, managing timelines and key deliverables as well as the quality control process (Audit) necessary to ensure benefits are set up accurately pre- and post-go live.
You will be responsible for the overall communication to leadership on the status including tracking and reporting for all lines of business.
As the Claims Surveillance Senior Advisor you?ll also be involved in proactive testing, planning, effective communication, coordination and project management of select organizational initiatives, action tracking and follow-up, and coordinating benefit automation projects in support of the Business Unit.
You will be responsible for ensuring organizational processes are optimally aligned and coordinated between and among groups and projects.
Focus areas include quality improvement, procedures, and workflow management.
Responsibilities of the position include daily operational oversight, support and analyze requests from the BI team, translate client requirements into requirements for BI team to create rules for monitoring, training & documentation
You'll be reviewing claims and determining anomalies,tracking, reporting, following up with cross team members on status. Additionally, there will be enhanced reporting and review of claims surveillance activities during the first 15 days of each month, with increased focus on the beginning and middle of the year. You will work with internal partners, peers and staff to ensure all work is done accurately and on time. As a Claims Surveillance Senior Advisor, you will be responsible for reviewing claims from complex client plan designs within the adjudication support system, driving automation and providing tactical and strategic directions for Claim surveillance roadmap. In this role you will also mentor junior level and consultants to ensure a successful Welcome Season and for all maintenance of business activities for new and existing clients.
You?ll accomplish this by:
Leading the way for RxClaim interpretation,analysis, and knowledge transfer to further strengthen claims surveillance activities.
Building and maintaining relationships with test centers of excellence, benefit coding teams and account management teams.
Analyzing, interpreting and comprehending complex client benefits requirements, commitments and contracts.
As a senior advisor, your success will be driven by exceeding client satisfaction score targets as well as contributing to reduced service warranty payments to clients.
Your healthcare industry knowledge, RXClaim/AS400 Coding experience and process improvement skills is critical to your success.
You will operate in a fast-paced environment with tight deadlines so ability to operate autonomously and make key decisions is imperative.
The contributions you will make will position CVS Health as a leader in client satisfaction and service in the PBM marketplace.
* Required Qualifications
4 or more years of benefit coding experience in AS400/RxClaim system and claims research
6 or more years of leading benefits projects
* Preferred Qualifications
* Dynamic individual contributor that thrives in a fast-paced, operational environment that is client-centric; where there is high variability between client plan designs, and is passionate about delivering superior quality.
* Demonstrated ability to make decisions independently by applying sound judgment based on business principles and supporting data facts.
* Strong interpersonal communication and presentation skills.
* Positive "can do" attitude with focus on the success of the team and Welcome Season efforts.\
* Possesses strong organizational and time management skills, and attention to detail and demonstrated ability to be accountable and independent.
* Advanced Microsoft Excel skills for data analysis and Macro development; proficient using other Microsoft Office applications including PowerPoint.
* Able to apply logical thinking and analytical skills to: research claims issues, formulate a strategic approach to efficiently build plans by performing analysis, and then execute and validate the plan build.
* Able to prioritize issues and operate in environment of regulatory compliance and audit.
* Able to meet aggressive turnaround time standards and client performance guarantees coupled with excellent quality.
* Education
* Bachelor's degree is required; equivalent work experience may substitute
* Master?s Degree is Preferred
Job Type: Full-time
Salary: $60,000.00 to $90,000.00 /year
Required education:
Bachelor's
Required experience:
RXClaims: 5 years
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