CVS Health is looking for a Senior Claim Benefit Specialist to review and adjudicate complex, sensitive, and specialized claims in accordance with plan processing guidelines. You will join a team passionate about transforming health care in a more connected, convenient, and compassionate way.
What You'll Do
- Review pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
- Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply cost containment measures to assist in the claim adjudication process.
- Handle phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.
- Ensure all compliance requirements are satisfied and all payments are made against company practices and procedures.
- Identify and report possible claim overpayments, underpayments and any other irregularities.
- Perform claim rework calculations.
- Distribute work assignment daily to junior staff.
- Train and mentor claim benefit specialists.
- Make outbound calls to obtain required information for claim or reconsideration.
What We're Looking For
- A current New York Independent Adjuster License.
- Demonstrated experience working in a production environment.
- Proven ability to handle multiple assignments competently, accurately, and efficiently.
- A High School Diploma.
Nice to Have
- 18+ months of medical claim processing experience.
- Self-Funding experience.
- Knowledge of the DG system.
- An Associates degree or equivalent work experience.
Benefits & Compensation
- Compensation range: $18.50 - $42.35 per hour.
- Affordable medical plan options.
- 401(k) plan with matching company contributions.
- Employee stock purchase plan.
- No-cost wellness screenings, tobacco cessation and weight management programs.
- No-cost confidential counseling and financial coaching.
- Paid time off.
- Flexible work schedules.
- Family leave.
- Dependent care resources.
- Colleague assistance programs.
- Tuition assistance.
- Retiree medical access.
Work Mode
This is a full-time position.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
