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
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