Senior Claim Benefit Specialist - Remote Adjudicator

CVS Health; Hawaii; Hybrid; USD 26,000 - 58,000; Full time

Job summary

CVS Health in Hawaii is seeking a claims adjudicator to review and resolve complex medical claims, guided by plan processing guidelines. You will act as a subject matter expert, coach teammates, and support customer service by addressing inquiries to ensure a positive member experience.

This full-time role requires at least 18 months of medical claim processing experience, attention to detail, and the ability to juggle multiple tasks in a high-volume environment.

Qualifications

• Minimum 18 months of medical claim processing experience.
• Experience in a high-volume, production-driven environment.
• 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 claim processing

Multitasking

Attention to detail

Customer service orientation

Education

Associates degree or equivalent

Job description

CVS Health in Hawaii is seeking a claims adjudicator to review and resolve complex medical claims, guided by plan processing guidelines. You will act as a subject matter expert, coach teammates, and support customer service by addressing inquiries to ensure a positive member experience.

This full-time role requires at least 18 months of medical claim processing experience, attention to detail, and the ability to juggle multiple tasks in a high-volume environment.