CrawlJobs Logo

Senior Claim Benefit Specialist

https://www.cvshealth.com/ Logo

CVS Health

Location Icon

Location:
United States , Work at Home

Category Icon
Category:
-

Job Type Icon

Contract Type:
Employment contract

Salary Icon

Salary:

18.50 - 42.35 USD / Hour
Save Job
Save Icon
Apply Position

Job Description:

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Job Responsibility:

  • Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines
  • Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues
  • Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience
  • Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise
  • Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication
  • Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures
  • Identifies and reports potential overpayments, underpayments, and other claim irregularities
  • Performs claim rework calculations as needed
  • Trains and mentors as needed to enhance team performance and technical proficiency
  • Conducts outbound calls to obtain required information for claims or reconsideration requests

Requirements:

  • Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator
  • Proven success working in a high‑volume, production‑driven environment
  • Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail
  • High School Diploma required

Nice to have:

  • Self-Funding experience
  • DG system knowledge
  • Preferred Associates degree or equivalent work experience
What we offer:
  • Medical, dental, and vision coverage
  • Paid time off
  • Retirement savings options
  • Wellness programs

Additional Information:

Job Posted:
May 10, 2026

Employment Type:
Fulltime
Work Type:
Remote work
Icon
CVS Health - All Job Offers
Job Link Share:
Copy Link Icon
Facebook Icon Twitter Icon LinkedIn Icon

Looking for more opportunities? Search for other job offers that match your skills and interests.

Briefcase Icon

Similar Jobs for Senior Claim Benefit Specialist

Senior Employee Benefits Specialist

Allied Universal® is hiring a Senior Benefits Specialist. The Senior Benefits Sp...
Location
Location
United States , Irvine
Salary
Salary:
24.00 - 28.00 USD / Hour
aus.com Logo
Allied Universal®
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • High school diploma or equivalent (e.g., GED)
  • Minimum of four (4) years of benefits administrative experience in a fast-paced environment
  • Knowledge of all pertinent federal and state regulations, filing and compliance requirements affecting employee benefits programs, including ERISA, ACA, COBRA, FMLA, ADA, Section 125, and DOL requirements
  • Ability to maintain sensitive information in a strictly confidential manner, exhibiting a high degree of ethics, professionalism and service orientation in all activities and all interactions with internal and external individual
  • Proactive problem solver and collaborative team player with strong attention to detail, flexibility, and initiative, exercising sound judgment and discretion while effectively operating with minimal supervision
  • Advanced proficiency in MS Office products (Word/Excel/PowerPoint/Outlook), and Internet and website navigation
  • analytical and technical support in the delivery of benefit administration
  • Outstanding verbal and written communication skills required with the ability to successfully interact at all levels of the organization while functioning as a team player
  • Willingness to take direction and critical feedback, and adapt to improve skills and effectiveness with a positive attitude
  • Must be able to manage multiple priorities and meet deadlines while maintaining attention to detail and handling stressful situations calmly and professionally in a fast-paced environment
Job Responsibility
Job Responsibility
  • Assist with benefits administration of group benefits programs (group health, dental, vision, short-term and long-term disability, life insurance and flexible spending plans) on a daily basis, including monitoring and researching weekly benefit deduction changes and updates
  • Serve as a subject matter expert and primary point of contact for employee benefit inquiries, providing high-quality service and support to colleagues and HR teams by resolving complex or escalated matters and assisting employees through the benefits hotline during open enrollment and other peak periods
  • Perform quality checks and audits to ensure accurate benefits data and compliance adherence, support compliance testing and annual audits, and investigate and resolve significant, complex, or unusual issues raised by management or colleagues
  • Serve as a liaison between colleagues and carriers, handing or facilitating requests for contribution adjustments, refunds, or other administrative changes
  • Act as liaison for all insurance carriers and third-party administrators for employee eligibility, claim and plan coverage inquiries, providing accurate and timely responses. Coordinates directly with third party administrators to research and resolve issues
  • Lead the implementation, testing, and maintenance of new and existing carriers EDI files with internal and external teams
  • Support both automated and manual benefits processes while documenting and maintaining detailed administrative procedures for all assigned benefit responsibilities, including upkeep of the benefits website and share drive to ensure accurate and accessible information
  • Assist with annual open enrollment activities, including the timeliness of elections to carriers, as well as the annual ACA reporting process by gathering data from third-party administrators, audits, research, and answering employees’ questions
  • Coordinate daily benefits processing. Handle enrollments, COBRA, terminations, qualifying life event changes, beneficiaries, disability, accident and death claims, and National Support Orders, Employee and Wage verifications, maintain group benefits database and update employee records
  • Assist with special projects assigned by management team
What we offer
What we offer
  • Medical, dental, vision, retirement plan, basic life, AD&D, and disability insurance
  • Eight paid holidays annually, five sick days, and four personal day
  • Vacation time offered at an accrual rate of 3.08 hours biweekly. Unused vacation is only paid out where required by law.
  • Fulltime
Read More
Arrow Right

Senior Leave and Workers Compensation Specialist

An exciting opportunity for a Senior Leave and Workers Compensation Specialist t...
Location
Location
United States , Milwaukie
Salary
Salary:
Not provided
https://www.roberthalf.com Logo
Robert Half
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Must be proficient in Accounting Software Systems
  • Familiarity with ADP - Financial Services is required
  • Proficiency in using ADP HRB and ADP Workforce Now is necessary
  • Experience with Ceridian is essential
  • Must have knowledge and experience in 401k - RRSP Administration
  • Auditing skills are necessary for this role
  • Demonstrated knowledge of Benefit Functions is required
  • Experience in Claim Administration is essential
  • Must be proficient in Cobra Administration within the Food & Food Processing industry
Job Responsibility
Job Responsibility
  • Oversee the Family and Medical Leave Act (FMLA) administration process, from the initial leave request to the employee's return to work
  • Serve as a point of contact for employees and managers for issues related to leave and workers' compensation
  • Handle the workers' compensation process from the moment of injury until the employee's return to work
  • Review all leave requests and supporting medical documentation
  • Communicate with employees about their leave needs and ensure they are aware of any necessary documentation and notice requirements
  • Provide technical support for workers' compensation claims, including settlement authority up to the authorized limit
  • Collaborate with the Total Rewards Team and Payroll to manage the Paid Leave Oregon program
  • Advise supervisors and managers on leaves of absence and accommodations
  • Oversee the return-to-work process for employees after FMLA, OFLA, workers' compensation, or other leaves
  • Facilitate other leave requests, including accommodation requests under the Americans with Disabilities Act (ADA)
What we offer
What we offer
  • Medical
  • Vision
  • Dental
  • Life and disability insurance
  • Eligibility to enroll in company 401(k) plan
Read More
Arrow Right

Senior Claim Benefit Specialist

We’re building a world of health around every individual — shaping a more connec...
Location
Location
United States
Salary
Salary:
18.50 - 42.35 USD / Hour
https://www.cvshealth.com/ Logo
CVS Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator
  • Proven success working in a high‑volume, production‑driven environment
  • Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail
  • High School Diploma required
Job Responsibility
Job Responsibility
  • Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines
  • Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues
  • Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience
  • Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise
  • Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication
  • Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures
  • Identifies and reports potential overpayments, underpayments, and other claim irregularities
  • Performs claim rework calculations as needed
  • Trains and mentors as needed to enhance team performance and technical proficiency
  • Conducts outbound calls to obtain required information for claims or reconsideration requests
What we offer
What we offer
  • Affordable medical plan options
  • 401(k) plan (including matching company contributions)
  • Employee stock purchase plan
  • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
  • Paid time off
  • Flexible work schedules
  • Family leave
  • Dependent care resources
  • Colleague assistance programs
  • Tuition assistance
  • Fulltime
Read More
Arrow Right

Senior Claims Management Specialist

As a Senior Specialist, you will manage the end-to-end lifecycle of disability c...
Location
Location
Canada , Mississauga
Salary
Salary:
40.00 - 45.00 CAD / Hour
https://www.randstad.com Logo
Randstad
Expiration Date
May 23, 2026
Flip Icon
Requirements
Requirements
  • Minimum five (5) years of claims-related work experience, specifically within a retail or distribution/warehouse environment
  • Deep understanding of workers' compensation (WSIB/WCB), Human Rights legislation, and Short/Long-Term Disability (STD/LTD) practices
  • Excellent written and verbal communication skills with the ability to present to senior leadership
  • Must possess a valid Driver’s License and access to a vehicle for travel to off-site meetings and mediations
  • Must be 18 years of age or older and able to pass a criminal record check
Job Responsibility
Job Responsibility
  • Process end-to-end non-occupational claims and temporary/permanent accommodations, including all related administration and record retention
  • Develop medically supported workplace accommodations for illness, injury, and mental health disabilities
  • implement sustainable work plans that balance associate needs with business operations
  • Manage competing priorities and resistance regarding accommodations that intersect both occupational and non-occupational injuries
  • Provide direction to third-party insurance providers and benefits vendors to negotiate and implement case management agreements
  • Act as a senior resource for the team, providing guidance on complex claims, talent acquisition accommodations, and legal/Open Door remedies
  • Accurately maintain database records in accordance with provincial governance and company reporting needs for potential legal hearings
What we offer
What we offer
  • Immediate access to Group Benefits, Employee & Family Assistance Programs, and well-being resources
  • Access to robust training and development resources designed to help you succeed
  • Work within a vibrant, inclusive environment that values integrity, respect, and teamwork
  • Generous corporate discounts across our national retail brands
!
Read More
Arrow Right

Senior HR Specialist

The Senior HR Specialist will play a key role in supporting comprehensive human ...
Location
Location
United States , Clifton
Salary
Salary:
Not provided
challengeprintingco.com Logo
The Challenge Printing Company Inc
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor’s degree in Human Resources, Business Administration, or a related field (HR concentration preferred)
  • Minimum of 5 years of progressive HR experience
  • experience in a manufacturing or regulated environment preferred
  • Strong working knowledge of federal, state, and local employment laws, with emphasis on New Jersey regulations
  • Experience administering FMLA and state-specific leave programs
  • Excellent verbal and written communication, presentation, and interpersonal skills
  • Strong organizational skills with the ability to multitask and prioritize in a fast-paced environment
  • Proficiency in Microsoft Word and Excel
  • Experience with Paylocity or other HRIS systems preferred
  • High level of professionalism, integrity, and discretion when handling confidential information
Job Responsibility
Job Responsibility
  • Administer employee benefit programs, including health, dental, life, disability, workers compensation, FMLA, and COBRA
  • Serve as a key point of contact for employees with questions regarding benefit plans and assist with claim resolutions
  • Oversee employee onboarding, orientation, and benefits enrollment
  • present benefits packages during orientation and facilitate 401(k) education and participation
  • Ensure employment-related documentation and reports are filed accurately with the appropriate regulatory bodies
  • Manage compensation programs and coordinate performance evaluations
  • recommend improvements as necessary
  • Participate in the review and selection of benefit plan offerings in partnership with senior management
  • Oversee the recruitment process including job postings, background checks, drug screenings, and E-Verify/I-9 compliance
  • Maintain and update personnel policies and procedures and ensure adherence to the Employee Handbook
  • Fulltime
Read More
Arrow Right

Senior Manager, Global Benefits

PerkinElmer is seeking an experienced Global Benefits Manager to join our Total ...
Location
Location
United States , Remote
Salary
Salary:
132500.00 - 150000.00 USD / Year
content.perkinelmer.com Logo
PerkinElmer
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor’s degree in business, finance, human resources, or a related field
  • 10+ years of progressive benefits experience, with significant depth in US self-insured health plan design, administration, and strategy
  • 2+ years of global benefits administration and familiarity with global pooling
  • CEBS (Certified Employee Benefit Specialist) or CBP (Certified Benefits Professional) designation preferred
  • Demonstrated experience managing consultant relationships and holding external partners accountable for performance and value delivery
  • Strong command of US benefits regulatory compliance, including ERISA, ACA, HIPAA, COBRA, FMLA, and related requirements
  • Experience managing open enrollment end-to-end, including testing and communications
  • Analytically strong — able to work with claims data, cost trend analysis, and financial modeling
  • comfortable presenting to senior leadership
Job Responsibility
Job Responsibility
  • Serve as primary owner of the US self-insured medical, prescription drug benefit and dental programs, with deep understanding of plan funding, claims administration, and stop-loss structure
  • Partner with the US consultant (WTW) and third-party administrators to manage plan performance, cost trends, and utilization, bringing forward proactive, creative recommendations to reduce trend
  • Own and manage relationships with all US benefits vendors including medical, dental, vision, life, disability, EAP and voluntary
  • Lead annual plan design review and renewal strategy in close partnership with WTW
  • Own the annual open enrollment process end-to-end
  • Develop and execute a communications strategy that is employee-centered
  • Create and maintain employee-facing benefit resources including guides, orientation, FAQs and change communications
  • Partner with HR Technology and benefits administration vendor to ensure accurate plan configuration
  • Act as the escalation point for complex employee benefits issues and appeals
  • Ensure plan documents, SPDs, and legal notices are accurate, current, and compliant
  • Fulltime
Read More
Arrow Right

Senior Benefits Specialist

The Benefits Specialist supports consultants and client teams by coordinating da...
Location
Location
United States , Plano
Salary
Salary:
Not provided
bbrown.com Logo
Brown & Brown UK
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor’s degree or equivalent work experience
  • 3+ years of employee benefits experience with strong foundational knowledge of group health & welfare plans
  • Proficiency in Microsoft Office Suite
  • Advanced to expert Excel skills required
  • Strong analytical and critical‑thinking capabilities
  • Excellent verbal and written communication skills
  • Ability to work independently, prioritize effectively, and apply sound judgment
  • Exceptional attention to detail and organizational skills
  • Ability to maintain confidentiality and handle sensitive information
  • Strong vendor knowledge and established carrier relationships
Job Responsibility
Job Responsibility
  • Prepare meeting materials, presentations, and follow‑up documentation
  • Maintain account action logs and track deliverables
  • Organize and manage client folders and documentation
  • Support Open Enrollment (OE) preparation, including OE decks, materials, and document review
  • Assist consultants with client deliverables, renewal prep, and reporting
  • Coordinate escalated claims issues and work directly with carriers and vendors to resolve them
  • Support benefit plan implementations, vendor calls, and ongoing operational updates
  • Manage RFP buildout, gather requirements, and submit marketing materials to carriers
  • Submit fees, commissions, and related administrative updates as needed
  • Review and interpret utilization reports and plan performance trends
What we offer
What we offer
  • Medical/Rx
  • Dental
  • Vision
  • Life Insurance
  • Disability Insurance
  • ESPP
  • 401k
  • Student Loan Assistance
  • Tuition Reimbursement
  • Free Mental Health & Enhanced Advocacy Services
  • Fulltime
Read More
Arrow Right

Configuration Analysis Senior Specialist

The Configuration Analysis Senior Specialist at NTT Data Services is responsible...
Location
Location
India , Chennai
Salary
Salary:
Not provided
nttdata.com Logo
NTT DATA
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Over all 5+ years’ experience in US healthcare Claims Payer
  • 8+ year(s) experience in Configuring client System for Pricing (Provider Contract) and UAT testing – 2+ Years
  • High school diploma or equivalent required
  • Associates degree, technical college or some college course work preferred
  • Ability to work within a project-oriented environment
  • Experience in SQL 2+ Years (Queries Writing)
  • Exposure on VB/Vb.net
Job Responsibility
Job Responsibility
  • Configuring client System for Pricing (Provider Contract) as per the requirement and according to defined business rules of new claims processing platform
  • Evaluation of Configuration Requirement and Formulation of Configuration Approach and Effectively include advanced configuration and additional functionality based on best practices
  • Based on the business requirements and business rules gathered, evaluate and create rules and complete the configuration activities
  • Participate in problem solving of Health Plan benefit, provider, pricing, reporting, operational and system issues
  • Perform a variety of tasks related to the resolution of production support issues based on client configurations with the core administrative system
  • Support activities to update configuration within the core claims processing system, typically within the areas of Provider Pricing
  • Support fee schedule changes including terms, affiliations and contract maintenance
  • Enable User Analysis Testing (UAT) and implement the modifications as suggested by the business owners and/or analyst
  • Creating manual test cases from Use cases, Functional specs and other requirement documents
  • Resolve coding/QA issues by managing Master Issue Logs and Fixing the high priority change requests which require immediate attention
Read More
Arrow Right