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:

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 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 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:

New York Independent Adjuster License
Experience in a production environment
Demonstrated ability to handle multiple assignments competently, accurately and efficiently

Nice to have:

18+ months of medical claim processing experience
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 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 09, 2025

Expiration:
October 01, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Claim Benefit Specialist