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Healthcare Contract Compliance Consultant - Senior
at CVS Health
As a Healthcare Contract Compliance Senior Consultant, you will ensure contractual and regulatory compliance as it relates to DME and medically billed third party programs. You will act as a liaison between internal departments and external contacts such as health plans, processors, medical billing vendors, and governmental agencies. Additionally, you will facilitate the initiation and on-going maintenance of the pharmacy system to ensure that CVS pharmacies are able to service and bill medical claims for patients of third-party programs, where CVS is contracted and/or enrolled.
Third Party Information Management
* Make informed decisions by thoroughly researching program documentation and requirements from health plans, state Medicaid and Medicare, relative to medical claim processing
* Serve as a subject matter expert for both internal and external representatives by researching program requirements, medical billing policies, compliance inquiries, and related issues
* Demonstrate care by proactively identifying and resolving potential operational issues
* Understand the terms of Payer contracts, and NCPDP Standards, to ensure CVS and plan compliance
* Support the contracting effort with vendors and other applicable internal teams relative to any application or credential requirements
* Translate, and clarify where needed, payer information and communicate to appropriate internal personnel, field management, and CVS pharmacy locations
* Compose third party articles for the Third Party Weekly Update, issue emergency communications via the pharmacy HUB, and post Medicaid related third party program requirements on the Intranet, as necessary
* Foster and maintain a professional and effective working relationship with contracted agencies
* Act as problem solving point of contact for issues received from internal and external representatives
* Collaborate with payers, internal departments, and field personnel, to implement process improvements for medical claim processing, to ensure program compliance and to enhance store level customer service
* Keep Payer Relations Contracting Directors and/or appropriate management apprised of problematic Payer related issues that may significantly impact claim processing
Plan Code Facilitation
* Evaluate third party information to determine if an internal system update is required
* Track plan changes via database, and prepare necessary documentation to facilitate new third-party plan codes and/or updates to existing codes
* Collaborate with appropriate internal Payer Relations team(s) to determine best approach for system updates, when needed
* Contribute to a high-performing team by looking for opportunities to achieve individual and broader team goals, while remaining flexible for changing business needs, to enable supportive, collaborative, and management of challenging work
* Assist with implementation of procedures, policies, and other projects as needed, to develop processes for efficient day to day payer and customer support
Our ideal candidate is someone who has excellent verbal and written communication skills, has a strong attention to detail with flawless execution, thinks independently and can offer solutions. We also look for someone with professionalism, the ability to problem solve, multi-task, excellent organizational skills, how to prioritize their book of business and a proven ability to collaborate with both internal and external representatives.
- Experience in medical/DME billing
- Healthcare experience
- Experience with Microsoft Office, including Excel, Access, and PowerPoint
- Bachelor's degree
- Verifiable High School Diploma or Equivalent
At CVS Health, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, sex/gender, sexual orientation, gender identity or expression, age, disability or protected veteran status or on any other basis or characteristic prohibited by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.