Senior Claims Benefit Specialist

CVS Health; Rhode Island; Vor Ort; USD 25.000 - 58.000; Vollzeit

Zusammenfassung

CVS Health in Rhode Island is seeking a full-time Medical Claims Specialist to review and adjudicate self-funded and fully insured claims, process refunds, and respond to provider and member inquiries. The role requires applying medical necessity guidelines, verifying eligibility, and ensuring accurate payments in a fast-paced environment.

The ideal candidate has about two years of claim processing experience, can manage multiple tasks precisely, and communicates effectively.

Qualifikationen

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

Aufgaben

• 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

Kenntnisse

Medical claim processing

Production environment

Multitasking

Communication skills

Ausbildung

High School Diploma or GED

Associate degree preferred

Jobbeschreibung

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.

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: 10/30/2026

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