Senior Claim Benefit Specialist Operations (Encounters)

4004 Aetna Medicaid Administrators; Arizona; Hybrid; USD 25,000 - 49,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Other resources

Job summary

CVS Health in the United States is seeking an experienced medical claims processor to adjudicate complex encounters and support multiple Medicaid plans. The role requires strong analytical skills and the ability to work in a fast-paced production environment.

The position demands proficiency with MS Office, independent work capabilities, and teamwork. It offers a full-time schedule (40 hours) with a comprehensive benefits package and opportunities for cross‑functional collaboration across

Qualifications

• Minimum 2 years of medical claims processing experience (Commercial, Medicaid, Medicare).
• Experience working in a production environment.
• Strong analytical and problem‑solving skills, especially in researching claims.
• Proficiency in MS Office Suite applications; Excel, Word, OneNote.
• Ability to work independently and as a team.

Responsibilities

• Researches, reviews, and adjudicates complex, sensitive, and specialized encounters in accordance with state‑specific processing guidelines.
• Adjudicate complex, sensitive, and specialized claims with accuracy in the claims processing system.
• Drive timely resolution of encounter errors using available resources, tools, and research.
• Balance competing priorities while supporting multiple markets.
• Partner cross‑functionally to resolve barriers to encounter acceptance.
• Contributes to the development of desktops and standardized procedures.

Skills

Claims processing

Analytical

MS Office

Teamwork

Independent work

Education

High School Diploma

Tools

QNXT

Facets

Edifecs

Job description

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

• Researches, reviews, and adjudicates complex, sensitive, and specialized encounters in accordance with state‑specific processing guidelines.
• This role requires medical claims processing experience and may involve supporting multiple Medicaid plans.
• Specialists correct encounters accurately and efficiently in a fast‑paced production environment.
• Drive timely resolution of encounter errors using available resources, tools, and research.
• Adjudicate complex, sensitive, and specialized claims with accuracy in the claims processing system.
• Consistently meet quality and production expectations.
• Identify and elevate issues that impact claim payment accuracy or create rework.
• Partner cross‑functionally to resolve barriers to encounter acceptance.
• Contributes to the development of desktops and standardized procedures.
• Balance competing priorities while supporting multiple markets.
• Engage in working sessions and meetings that advance business objectives and Key Performance Indicators (KPI).

Required Qualifications

• Minimum 2 years of medical claims processing experience (Commercial, Medicaid, Medicare).
• Experience working in a production environment.
• Strong analytical and problem‑solving skills, especially in researching claims.
• Proficiency in MS Office Suite applications; Excel, Word, OneNote.
• Ability to work independently and as a team.

Preferred Qualifications

• QNXT or Facets claims processing experience.
• Experience in Medicaid or Medicare claims.
• Encounters experience.
• Edifecs system knowledge.

Education

High School Diploma

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $18.50 - $35.29

This pay range represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

Our people fuel our future.

Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.

• medical coverage
• dental coverage
• vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 11/13/2026.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people.

Our employees are self‑disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.