Senior Claims Benefit Specialist, CVS Health

CVS Health

Location:
United States

Category:
Customer Service

Contract Type:
Employment contract

Salary:

18.50 - 38.82 USD / Hour

Save Job

Apply Position

Job Description:

Reviews and adjudicates complex claims, provides training and coaching, and handles inquiries related to pre-approvals or appeals, while ensuring compliance with company procedures.

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
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 assignments daily to junior staff
trains and mentors claim benefit specialists
makes outbound calls to obtain required information for claim or reconsideration

Requirements:

2+ years medical claim processing experience
1-2 years experience in a production/metrics based environment
demonstrated ability to handle multiple assignments competently, accurately, and efficiently

Nice to have:

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
benefit solutions including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access

Additional Information:

Job Posted:
April 30, 2025

Expiration:
May 01, 2025

Employment Type:

Fulltime

Work Type:

Remote work

View All Jobs In This Company

Job Link Share:

Senior Claims Benefit Specialist