Position SummaryThe
Senior Claims Research Coordinator is essential in driving claims adjudication projects and assisting with healthcare analytics, including (but not limited to), pulling and/or validation of claims data for submission to various departments, as well as the state of Illinois. This role focuses on claims management and ensuring effective and accurate claims processing. With an understanding of QNXT (or other claims payer system platforms) and a strong healthcare background, this coordinator will take charge of reviewal, initiation, and submission of high dollar claims projects, as well as conducting root cause analysis where necessary, in order to determine drivers for claim issues. The individual will provide essential technical support and claims processing insights to both external clients and internal stakeholders, including executive leadership.
The
Senior Claims Research Coordinator position requires a proactive individual with a strategic mindset, eager to deploy their expert claims knowledge and analytical skills to enhance our healthcare information and claims management systems. Additionally, the role demands a meticulous approach to data validation, manipulation, preparation, and complex analysis, in order to document activities and produce insightful & impactful outcomes in the claims space.
Core Responsibilities- Conduct comprehensive research and data analysis, ensuring the highest level of data quality and insightful reporting on claim drivers/outcomes.
- Utilize advanced understanding of medical claims processing, leveraging this knowledge to support and innovate within the claims analysis function.
- Establish and maintain a strategic consultative relationship with both internal teams and external clients, becoming the go-to expert for claims analysis and development.
- Offer authoritative oversight and feedback on data quality, directly contributing to service improvement and design advancement.
- Execute dedicated research and root cause analysis to pinpoint issues within the claims process and recommend evidence-based solutions.
- Perform other duties as needed.
Required Qualifications- 2+ years of experience with claims processing, including a demonstrated familiarity with automated medical claims payment systems and/or payer systems (i.e. Facets, QNXT, etc.)
- 2+ years of experience in data interpretation and analysis, including utilizing SQL to pull and manipulate large data sets, coupled with the ability to interpret and manipulate those same data sets.
- Willingness to work Monday-Friday from 8am-5pm CST.
- Willingness to travel up to 10% of the time within the continental United States.
Preferred Qualifications- Previous experience with state Medicaid, particularly in Illinois.
- Superlative communication abilities, encompassing both verbal and written formats, to clearly convey complex information and recommendations.
- Proven track record of configuration experience within a claims system environment.
- In-depth research abilities and significant experience in conducting root cause analysis in claims or related fields.
- An aptitude for working independently, as well as part of a team, with a keen eye for detail and problem-solving.
- Knowledge and experience with SQL-type programs for the purpose of pulling specific claim files and validating accuracy.
Education- Associate's degree or equivalent work experience (high school diploma or GED + 2+ years of relevant experience).
Anticipated Weekly Hours40
Time TypeFull time
Pay RangeThe typical pay range for this role is:
$46,988.00 - $122,400.00
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.
Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 08/10/2026
