Senior Claims Benefit Specialist

4062 Aetna Resources, LLC; Minnesota; Hybrid; USD 34,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Other resources

Job summary

CVS Health is seeking a dedicated Claims Processor to review and adjudicate self-funded, fully insured, and RX claims in Minnesota. You will apply medical necessity guidelines, verify eligibility, and resolve overpayments or underpayments while handling refunds and inquiries.

In a production environment, you’ll manage multiple claims with accuracy and strong communication, following company policies to ensure compliant payments and timely resolutions for providers and members.

Qualifications

• 2+ years medical claim processing experience.
• Experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communications, organizational, and interpersonal skills.

Responsibilities

• Review and adjust SF, FI, Reinsurance, and RX claims per guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across all dollar amounts on claims platforms.
• Apply medical necessity guidelines and determine coverage.
• Process overpayments, underpayments and other irregularities.

Skills

Medical claim processing

Production environment

Communication skills

Multi-tasking

Education

High School Diploma or GED

Associate degree preferred

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

Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Process provider refunds and returned checks. May handle customer service inquiries and problems. Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Performs claim re-work calculations. Follow through completion of claim overpayments, underpayments, and any other irregularities. Process complex non-routine Provider Refunds and Returned Checks. Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks. Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals. Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures. Review and handle relevant correspondences assigned to the team that may result in adjustment to claims. May provide job shadowing to lesser experience staff. Utilize all resource materials to manage job responsibilities.

Required Qualifications

• 2+ years medical claim processing experience.
• Experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communications, organizational, and interpersonal skills.

Preferred Qualifications

• DG system claims processing experience.
• Associate degree preferred.

Education

High School Diploma or GED.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $18.50 - $42.35. 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.

Great benefits for great people

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

Application Window

We anticipate the application window for this opening will close on: 10/02/2026

Background and Eligibility

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

Our Work Experience

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.