Senior Claim Benefit Specialist, CVS Health

CVS Health

Location:
United States

Category:
Customer Service

Contract Type:
Employment contract

Salary:

18.50 - 38.82 USD / Hour

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Job Description:

The Senior Claim Benefit Specialist serves as a quality champion and advocate for the business by conducting routine audits and claim testing related to PPO network creation. This role supports the continuous improvement of work processes that impact customer satisfaction, medical cost management, and operational efficiency. The specialist collaborates cross-functionally to promote compliance, identify trends, and drive quality initiatives.

Job Responsibility:

Conduct standard quality reviews and audits to ensure compliance with internal policies, procedures, and regulatory guidelines
identify, document, and communicate errors to business partners for resolution
support daily operations and maintenance of assigned functional units
analyze audit data to identify trends and recommend process improvements
participate in special projects and targeted quality audit initiatives
provide subject matter expertise on workflows, systems, and operational procedures
collaborate with business owners to support the design and implementation of new processes
develop and implement quality programs and contribute to test plan development
analyze and resolve complex claims scenarios within established timeframes
respond to internal and external customer inquiries and complaints
monitor and reconcile system activity to ensure data integrity and financial accuracy

Requirements:

1–2+ years of experience in a quality audit or claims testing environment
working knowledge of PPO networks and healthcare claims processing
strong analytical and problem-solving skills
proficiency in using systems and tools for data analysis and auditing

Nice to have:

1-2 year of DG Claims systems experience
experience with quality assurance programs in a healthcare or insurance setting
familiarity with regulatory compliance standards
excellent communication and collaboration skills
ability to manage multiple priorities and meet deadlines

What we offer:

Affordable medical plan options
a 401(k) plan (including matching company contributions)
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 including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access

Additional Information:

Job Posted:
September 13, 2025

Expiration:
September 22, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Claim Benefit Specialist