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, or responding to complex issues. May 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, or responding to complex issues
Handles customer service inquiries and problems
Reviews pre-specified claims or claims that exceed specialist adjudication authority
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 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
High School Diploma required
Preferred Associates degree or equivalent work experience

Nice to have:

Self-Funding experience
DG system knowledge

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
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:
September 18, 2025

Expiration:
October 03, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Claim Benefit Specialist