• Job Description

  Req#: R0572255

  At CVS Health, 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 reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

  Remote: can work anywhere in the US

  Position Summary

  Medicaid Claim Editing Content Management team. Must oversee ongoing content delivery and maintenance across Medicaid claim editing vendors on QNXT, including supporting the Claim Editing Content Management and Claim Editing Provider Disclosure Tools; testing ClaimsXten deployments; managing system enhancements, customizations, and deviations to support ClaimsXten and Cotiviti; and maintenance of each health plan's service code, modifier, svccodemod exception list).

  Ad hoc project management and support for MPPS claim editing initiatives, including claim analytics and coding reviews for Medicaid health plans, handling coding questions for claims, contracts, benefits, and references files (CPT, ICD 10, Modifiers, ICD 10

  Procedure Codes, Revenue Codes, and DRGs) and identify and facilitate resolutions to configuration, processing, and billing issues. In addition, must oversee

  Medicaid Pre Implementation Testing (QA testing to validate PPM edits are set up correctly prior to being sent to Cotiviti, project implementation and new rule testing (Development, System, SQA, and UAT testing, and testing for implementation of ClaimsXten for all Medicaid health plans). Also responsible for Medicaid PPM QNXT Claim Editing QA Process (Post Implementation Validation via Daily Edit Recommendation Reviews), PPM QNXT Claim Analytics (Monthly Unreconciled, Monthly Discrepancy, and ad hoc claim

  
  
  Required Qualifications
  Demonstrated Leadership Skills
  *Experience with system testing and post go-live validation
  Familiarity with clinical and code editing concepts and
  products (Example: Claim Check, ClaimsXten, Cotiviti PPM & CV)
  • Extensive knowledge of CPT, HCPCS, ICD-10 coding
  • Must be willing to work 1-2 Sundays each month for
  content updates
  • Ability to prioritize and work in a fast paced, deadline
  oriented environment
  • Excellent critical thinking skills
  • Analytical and creative problem-solving abilities
  
  Preferred Qualifications

  Clinical Coding Experience - Content Manager

  Claim Processing Medicaid

  Working with SQL Application

  Experience managing a complex team with diverse skillsets

  QNXT Experience
  Understanding of claim processing guidelines
  Understanding of referral & service authorization
  requirements and logic
  Knowledge of legal, regulatory, and policy
  compliance issues related to medical coding and
  billing procedures and documentation
  Data query and analysis skills
  
  Education Diploma or Associates, Bachelor's preferred

  Anticipated Weekly Hours

  40

  Time Type

  Full time

  Pay Range

  The typical pay range for this role is:

  $54,300.00 - $145,860.00

  This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base 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 all 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, visit https://jobs.cvshealth.com/us/en/benefits

  We anticipate the application window for this opening will close on: 06/27/2025

  Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

• About the company

  At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.

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