Senior Claim Benefit Specialist - Remote
About the position
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. Position Summary Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience.
Responsibilities
- Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise.
- Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication.
- Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures.
- Identifies and reports potential overpayments, underpayments, and other claim irregularities.
- Performs claim rework calculations as needed.
- Trains and mentors as needed to enhance team performance and technical proficiency.
- Conducts outbound calls to obtain required information for claims or reconsideration requests.
Requirements
- 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-haves
- Self-Funding experience
- DG system knowledge
- Preferred Associates degree or equivalent work experience.
Benefits
- medical coverage
- dental coverage
- vision coverage
- paid time off
- retirement savings options
- wellness programs
