Remote Senior Medical Claims Specialist - Expert Adjudication

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a Claims Adjudicator to review and adjudicate complex medical claims in line with plan guidelines, acting as a subject matter expert and mentoring teammates to improve accuracy and efficiency.

You will apply medical necessity guidelines, verify eligibility, and identify discrepancies to support accurate adjudication while ensuring regulatory compliance and positive member experiences.

Qualifications

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

Responsibilities

• Reviews pre‑specified claims and those beyond specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures.
• Ensures compliance with regulatory requirements and confirms payments align with policies and procedures.
• Identifies and reports potential overpayments, underpayments, and other claim irregularities.
• Performs claim rework calculations as needed.
• Trains and mentors to enhance team performance and technical proficiency.
• Conducts outbound calls to obtain required information for claims or reconsideration requests.

Education

High School Diploma

Associates degree or equivalent

Job description

CVS Health is seeking a Claims Adjudicator to review and adjudicate complex medical claims in line with plan guidelines, acting as a subject matter expert and mentoring teammates to improve accuracy and efficiency.

You will apply medical necessity guidelines, verify eligibility, and identify discrepancies to support accurate adjudication while ensuring regulatory compliance and positive member experiences.