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Senior Claim Benefit Specialist

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States, Work At Home

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Category:
Customer Service

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Contract Type:
Employment contract

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Salary:

18.50 - 42.35 USD / Hour

Job Description:

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Job Responsibility:

  • Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise
  • Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process
  • Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals
  • Ensures all compliance requirements are satisfied and all payments are made against company practices and procedures
  • Identifies and reports possible claim overpayments, underpayments and any other irregularities
  • Performs claim rework calculations
  • Distributes work assignment daily to junior staff
  • Trains and mentors claim benefit specialists
  • Makes outbound calls to obtain required information for claim or reconsideration.

Requirements:

  • 18+ months of medical claim processing experience
  • Experience in a production environment
  • Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Nice to have:

  • Self-Funding experience
  • DG system knowledge
What we offer:
  • Affordable medical plan options
  • 401(k) plan (including matching company contributions)
  • Employee stock purchase plan
  • No-cost programs 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
  • Retiree medical access.

Additional Information:

Job Posted:
May 14, 2025

Expiration:
July 31, 2025

Employment Type:
Fulltime
Work Type:
Remote work
Job Link Share:
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