Medicare PDE & Claims Integrity Analyst

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

Job summary

CVS Health in Wisconsin seeks a Senior Claims Analyst responsible for reviewing claims and PDE errors, analyzing PDE rejections, and coordinating research with internal teams and external clients to meet CMS deadlines. You will support weekly PDE meetings and drive continuous improvement of Medicare data.

A Bachelor’s degree or equivalent work experience is preferred, with 3+ years in government-regulated health programs. Strong communication and coordination skills are essential.

Qualifications

• 3 years minimum experience with government-regulated health programs within financial operations and/or related experience (Medicaid, Medicare, and/or Exchanges).
• Excellent written and verbal communication skills for interaction with clients, internal partners, and government agencies.
• Strong organizational skills and ability to manage multiple projects simultaneously.
• Excellent time management skills as these requests are time sensitive.
• Proficiency with Microsoft Word and Excel.
• Proficiency with SQL and/or Python.
• Bachelor's degree preferred or equivalent work experience required.

Responsibilities

• Review claims and PDE (Prescription Drug Event) errors and analyze PDE Rejections reports.
• Serve as liaison between the PDE Reporting Team, PDE Eligibility/Reconciliation and related entities.
• Coordinate research with various departments and submit responses to external clients or Acumen per CMS deadlines.
• Assist with weekly PDE meetings and drive continuous improvement of Medicare claims data through root-cause analysis.
• Study and interpret CMS Guidance and ensure compliance with CMS requirements.

Skills

Communication

Organizational skills

Time management

MS Word

MS Excel

SQL

Python

Education

Bachelor's degree preferred or equivalent work experience

Tools

Word

Excel

SQL

Python

Job description

CVS Health in Wisconsin seeks a Senior Claims Analyst responsible for reviewing claims and PDE errors, analyzing PDE rejections, and coordinating research with internal teams and external clients to meet CMS deadlines. You will support weekly PDE meetings and drive continuous improvement of Medicare data.

A Bachelor’s degree or equivalent work experience is preferred, with 3+ years in government-regulated health programs. Strong communication and coordination skills are essential.