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CVS Health Logo CVS Health · Customer Service

Senior Claims Benefit Specialist

United States Employment contract 18.50 - 42.35 USD / Hour · Job Posted June 14, 2026
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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

  • Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims
  • adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines
  • Process provider refunds and returned checks
  • May handle customer service inquiries and problems
  • Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise
  • Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
  • Performs claim re-work calculations
  • Follow through completion of claim overpayments, underpayments, and any other irregularities
  • Process complex non-routine Provider Refunds and Returned Checks
  • Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks
  • Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals
  • Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures
  • Review and handle relevant correspondences assigned to the team that may result in adjustment to claims
  • May provide job shadowing to lesser experience staff
  • Utilize all resource materials to manage job responsibilities

Requirements

  • 2+ years medical claim processing experience
  • Experience in a production environment
  • Demonstrated ability to handle multiple assignments competently, accurately, and efficiently
  • Effective communications, organizational, and interpersonal skills

Nice to have

  • DG system claims processing experience
  • Associate degree preferred

What we offer

  • Medical, dental, and vision coverage
  • paid time off
  • retirement savings options
  • wellness programs
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