Medicare PDE & Claims Analytics Lead

CVS Health; Louisiana; Hybrid; USD 47,000 - 112,000; Full time

Job summary

CVS Health is seeking a claims specialist to review PDE errors and manage PDE rejection analyses. You will coordinate with the PDE Reporting Team, Eligibility/Reconciliation, and other stakeholders to ensure timely resolutions aligned with CMS deadlines.

You will analyze outliers, prepare responses for external clients, and participate in weekly PDE meetings. A background in Medicare Part D and proficiency with SQL/Python are preferred.

Qualifications

• 3 years minimum experience with government-regulated health programs within financial operations and/or related experience (Medicaid, Medicare, and/or Exchanges).
• Experience with SQL and/or Python.
• Proficiency with Microsoft Word and Excel.

Responsibilities

• Review claims and PDE errors and analyze PDE Rejections.
• Coordinate research with various departments and submit responses to external clients per CMS deadlines.
• Serve as liaison between the PDE Reporting Team, PDE Eligibility/Reconciliation and other entities to ensure timely resolution of PDE Rejections.
• Assist with the weekly PDE meetings and drive continuous improvement of Medicare claims data through root cause analysis.
• Ensure compliance with CMS guidance and applicable regulations.

Skills

Government-regulated health programs

Financial operations

Medicaid/Medicare/Exchanges experience

Education

Bachelor's degree preferred or equivalent experience

Tools

SQL

Python

Microsoft Word

Excel

Job description

CVS Health is seeking a claims specialist to review PDE errors and manage PDE rejection analyses. You will coordinate with the PDE Reporting Team, Eligibility/Reconciliation, and other stakeholders to ensure timely resolutions aligned with CMS deadlines.

You will analyze outliers, prepare responses for external clients, and participate in weekly PDE meetings. A background in Medicare Part D and proficiency with SQL/Python are preferred.