Medical Claim Analyst

Position Summary

The Medical Claim Analyst is responsible for the initial review, assessment, and triage of assigned claims. This role determines coverage, verifies member eligibility, identifies and redirects misrouted requests, and prepares authorizations within designated systems for clinical review. The position requires strong organizational skills and the ability to prioritize work effectively to meet regulatory requirements and established claim turnaround times. The Claims Review Coordinator serves as a key liaison between internal teams, healthcare providers, and external stakeholders to support effective medical management services and positive member outcomes. Additional responsibilities include conducting non-clinical research, maintaining accurate and complete documentation, assisting with claims payment issue resolution, and ensuring compliance with company policies, regulatory standards, accreditation requirements, and confidentiality guidelines.

Responsibilities

• Conduct initial review and triage of assigned claims and authorization requests.
• Verify member eligibility and benefits coverage.
• Identify and redirect misrouted claims or requests to the appropriate department.
• Prepare and process authorizations for clinical review by medical staff.
• Prioritize workload to meet regulatory requirements and turnaround time standards.
• Collaborate with internal and external stakeholders to support medical management activities.
• Perform non-clinical research and administrative support functions.
• Maintain accurate, complete, and timely documentation in accordance with company, regulatory, and accreditation standards.
• Protect the confidentiality of member information and comply with all privacy and security policies.
• Investigate and assist in resolving claims payment issues.
• Support continuous improvement of service quality and member experience.

Required Qualifications

• Excellent organizational, time management, and prioritization abilities.
• Basic knowledge of medical terminology and healthcare concepts.
• Proficiency with Microsoft Office applications, including Excel and Word.
• Ability to navigate multiple internal and external computer systems efficiently.
• Understanding of benefits administration and management, claims processing and payment management, claims policies and procedures, general business operations, clinical and medical management concepts, and critical thinking and sound decision-making skills.

Preferred Qualifications

• 2 to 4 years of experience in one or more of the following: medical assistant role, medical office administration, healthcare claims processing, utilization management or authorization support.
• Experience using healthcare systems such as CECHR, PRumba, or MedCompass.

Education

High School Diploma or GED required.

Schedule

40 hours per week, full time.

Pay

$18.50 - $31.72 per hour. Actual base salary offer depends on 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.

Benefits

This full‑time position is eligible for a comprehensive benefits package including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources based on eligibility.