Senior Medicare Claims & PDE Analyst

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

Job summary

CVS Health is seeking a dedicated claims reviewer to analyze PDE errors and manage rejections, ensuring accurate resolution and CMS compliance. You will coordinate with the PDE Reporting Team, Eligibility/Reconciliation, and other departments to meet CMS deadlines and improve Medicare data quality.

The role requires 3+ years in government-regulated health programs and a Bachelor's degree (or equivalent experience).

Qualifications

• 3 years minimum experience with government-regulated health programs within financial operations and/or related experience (Medicaid, Medicare, and/or Exchanges).
• Bachelor's degree preferred or equivalent work experience required.

Responsibilities

• Review claims and PDE (Prescription Drug Event) errors.
• Analyze and distribute the PDE Rejections reports and analysis to internal and external clients.
• Serve as liaison between PDE Reporting Team, PDE Eligibility/Reconciliation and all involved entities to ensure timely resolution of PDE Rejections.
• Download and review the Acumen Outliers and coordinate research with various departments.
• Submit responses to external clients or Acumen according to CMS deadlines.
• Assist with the weekly PDE meetings and ensure continuous improvement of Medicare claims data through root cause analysis.
• Study and correctly interpret CMS Guidance; ensure compliance with CMS requirements.

Skills

Communication

Time management

Organizational skills

Education

Bachelor's degree or equivalent work experience

Tools

SQL

Python

Microsoft Excel

Microsoft Word

Job description

CVS Health is seeking a dedicated claims reviewer to analyze PDE errors and manage rejections, ensuring accurate resolution and CMS compliance. You will coordinate with the PDE Reporting Team, Eligibility/Reconciliation, and other departments to meet CMS deadlines and improve Medicare data quality.

The role requires 3+ years in government-regulated health programs and a Bachelor's degree (or equivalent experience).