Medical Claims Negotiator

At reputed company, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. 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 reputed company cases to ensure risk is managed and a proposed reputed company can be set to reputed company negotiation process, to include but not limited to, reviewing clinical picture, benchmarking value of service/supply/drug (reputed company 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 reputed company, high dollar cases, and drafting documentation supporting reputed company 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 reputed company coordinator, to client management team, and networking to handle reputed company 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 reputed company 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 reputed company subject matter. Education Bachelor's degree preferred/specialized training/relevant professional qualification. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $46,988.00 - $112,200.00 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company 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. • No-cost programs for reputed company 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, visithttps://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 03/28/2025 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply Job!