CVS Health is looking for a Senior Claim Benefit Specialist to review and adjudicate complex, sensitive, and specialized medical claims. In this remote role, you will function as a subject matter expert, provide coaching and guidance on escalated issues, and support customer service operations by addressing inquiries and resolving issues.
What You'll Do
- Review pre-specified claims and those that exceed specialist adjudication authority or processing expertise.
- Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and implement cost-containment measures to support accurate claim adjudication.
- Ensure compliance with all regulatory requirements and confirm that payments align with company policies and procedures.
- Identify and report potential overpayments, underpayments, and other claim irregularities.
- Perform claim rework calculations as needed.
- Train and mentor as needed to enhance team performance and technical proficiency.
- Conduct outbound calls to obtain required information for claims or reconsideration requests.
What We're Looking For
- Minimum of 18 months of medical claim processing experience with a health insurance payor or third-party administrator.
- Proven success working in a high-volume, production-driven environment.
- Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail.
- High School Diploma required.
Nice to Have
- Self-Funding experience.
- DG system knowledge.
- Associates degree or equivalent work experience.
Benefits & Compensation
- Compensation: $18.50 - $42.35 per hour.
- 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.
Work Mode
This is a fully remote position.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
