Remote Senior Medical Claims & Benefit Specialist

CVS Health; Wyoming; Hybrid; USD 25,000 - 58,000; Full time

Benefits offered by this job

Comprehensive benefits package

Job summary

CVS Health in the United States is seeking a claims adjudicator to review complex medical claims, apply guidelines, verify eligibility, and ensure compliant, accurate adjudication. You will coach colleagues and support customer service operations by resolving issues to improve member experience.

The role requires at least 18 months of medical claim processing experience, the ability to handle multiple tasks in a high‑volume setting, and strong attention to detail.

Qualifications

• 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.

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.

Skills

Medical claims processing

Attention to detail

High-volume environment

Education

High School Diploma

Associates degree or equivalent

Job description

CVS Health in the United States is seeking a claims adjudicator to review complex medical claims, apply guidelines, verify eligibility, and ensure compliant, accurate adjudication. You will coach colleagues and support customer service operations by resolving issues to improve member experience.

The role requires at least 18 months of medical claim processing experience, the ability to handle multiple tasks in a high‑volume setting, and strong attention to detail.