Senior Claim Benefit Specialist, CVS Health

Senior Claim Benefit Specialist

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:

The Senior Claim Benefit Specialist reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines. They will act as a subject matter expert by providing training, coaching, or responding to complex issues. May also handle customer service inquiries and problems.

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:

2+ years of medical claim processing experience
Previous experience in a production environment
Demonstrated ability to handle multiple assignments competently, accurately and efficiently

Nice to have:

Self funded medical claim processing experience
DG system knowledge
Associate's Degree

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:
August 17, 2025

Expiration:
August 27, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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