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Senior Claim Benefit Specialist

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States

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Category:
Customer Service

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Contract Type:
Not provided

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Salary:

18.50 - 42.35 USD / Hour
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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:
  • 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
  • Retiree medical access

Additional Information:

Job Posted:
February 22, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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