Senior Claim Benefit Specialist - Pharmacy (RX)

CVS Health; Ohio; Hybrid; USD 25,000 - 53,000; Full time

Benefits offered by this job

Bonus eligibility

Job summary

CVS Health in Ohio is seeking a Pharmacy Claims Specialist to review and correct pharmacy-related claim issues, ensuring accurate benefit administration and regulatory compliance. The role requires strong analytical skills and the ability to work independently while meeting productivity targets.

You will perform routine and non-routine support for the Claim Benefit area, identify overpayments/underpayments, and follow established protocols.

Qualifications

• 2+ years medical claim processing experience.
• Experience in a production environment.
• Knowledge of pharmacy claims, benefits and adjustment processes.
• Ability to interpret data from reports and spreadsheets.
• Effective written and verbal communication skills.
• DG system claims processing experience.

Responsibilities

• Research, review, and correct pharmacy-related claim issues to ensure accurate benefit administration.
• Execute routine and non-routine business support tasks for the Claim Benefit area under limited supervision.
• Identify and report claim overpayments, underpayments and other irregularities.
• Follow area protocols, standards, and policies to provide timely support.

Skills

Attention to detail

Analytical skills

Problem solving

Communication skills

Education

Associate degree or equivalent experience

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

Responsible for researching, reviewing, and correcting pharmacy-related claim issues to ensure accurate benefit administration, financial accuracy, and compliance with client and regulatory requirements. The role requires strong analytical skills, attention to detail, and the ability to work independently while meeting productivity and quality expectations. Executes both routine and non-routine business support tasks for the Claim Benefit area under limited supervision, referring deviations from standard practices to managers. Follows area protocols, standards, and policies to provide effective and timely support. Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise. Identifies and reports claim overpayments, underpayments, and any other irregularities. Takes direction to execute techniques, processes, and responsibilities.

Required Qualifications

2+ experience in a production environment. 2+ years medical claim processing experience.

Preferred Qualifications

Knowledge of pharmacy claims, benefits, and adjustment processes. Attention to detail and accuracy. Strong analytical and problem-solving skills. Ability to interpret data from reports and spreadsheets. Effective written and verbal communication skills. Ability to manage multiple priorities and work independently. DG system claims processing experience.

Education

Associate degree or equivalent experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $18.50 - $38.82

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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

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. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and 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: 11/24/2026

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.