Remote Senior Medical Claims Specialist - Adjudication

CVS Health; Montana; Hybrid; USD 25.000 - 58.000; Vollzeit

Benefits dieser Stelle

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Benefits Details during application

Zusammenfassung

CVS Health is hiring for a claims adjudication specialist to review complex medical claims and support customer service by resolving issues for a positive member experience. The role involves coaching teammates, ensuring compliance, and applying medical necessity guidelines to determine coverage.

The position requires at least 18 months of medical claim processing experience, strong attention to detail, and the ability to manage multiple tasks in a fast-paced setting.

Qualifikationen

• Minimum 18 months of medical claim processing experience.
• Proven success in a high-volume, production-driven environment.
• Ability to manage multiple assignments with accuracy and efficiency.

Aufgaben

• Reviews pre-specified claims and those beyond specialist adjudication authority.
• Applies medical necessity guidelines, determines coverage, verifies eligibility, and identifies discrepancies.
• Ensures 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 teammates to enhance team performance and technical proficiency.
• Conducts outbound calls to obtain required information for claims or reconsideration requests.

Kenntnisse

Medical claims processing

High-volume environment

Attention to detail

Ausbildung

High School Diploma

Associates degree or equivalent

Jobbeschreibung

CVS Health is hiring for a claims adjudication specialist to review complex medical claims and support customer service by resolving issues for a positive member experience. The role involves coaching teammates, ensuring compliance, and applying medical necessity guidelines to determine coverage.

The position requires at least 18 months of medical claim processing experience, strong attention to detail, and the ability to manage multiple tasks in a fast-paced setting.