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CVS Health Logo CVS Health · -

Senior Claim Benefit Specialist

United States, Work at Home Employment contract 18.50 - 42.35 USD / Hour · Job Posted May 10, 2026
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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
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