Senior Claim Benefit Specialist, CVS Health

CVS Health

Location:
United States

Category:
Customer Service

Contract Type:
Not provided

Salary:

18.50 - 42.35 USD / Hour

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Job Description:

Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, and/or responding to complex issues. May also handle customer service inquiries and problems.

Job Responsibility:

Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines
Acts as a subject matter expert by providing training, coaching, and/or responding to complex issues
Handles customer service inquiries and problems
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
Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals
Ensures all compliance requirements are satisfied
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:

At least 18 months of experience in medical claim processing
At least 18 months of experience in a production environment
High school diploma or GED

Nice to have:

Demonstrated ability to handle multiple assignments competently, accurately and efficiently
Previous experience with self-funding
Demonstrated knowledge of and proficiency with DG system
Associate's degree or higher

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
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:
October 05, 2025

Expiration:
October 10, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Claim Benefit Specialist