Senior Claims Benefit Specialist

CVS Health; United States; Remote; USD 80,000 - 100,000; Full time

Job summary

Join a leading health solutions company as a Senior Claims Benefit Specialist, where you'll play a crucial role in processing and adjusting complex health claims. Your expertise in medical claim processing and customer service will ensure accurate and timely handling of provider refunds and claim inquiries. With numerous opportunities for professional growth, you'll contribute to CVS Health's mission of helping people lead healthier lives. Enjoy a competitive hourly wage, comprehensive benefits, and support in a vibrant work culture.

Benefits

Affordable medical plan options

401(k) plan (including matching company contributions)

Employee stock purchase plan

No-cost wellness programs

Paid time off and flexible work schedules

Tuition assistance

Qualifications

• 2+ years of experience with medical claim processing.
• Experience in a production environment is required.

Responsibilities

• Review and adjust SF, FI, Reinsurance, and RX claims.
• Handle customer service inquiries and resolve problems related to claims.
• Perform complex claim adjustments using technical expertise.

Skills

Organizational skills

Communication skills

Interpersonal skills

Education

Associate’s degree or equivalent experience

Tools

DG system claims processing

Job description

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

The Senior Claims Benefit Specialist will review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims. They will adjudicate complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. This person will also process provider refunds and returned checks. They also may handle customer service inquiries and problems.

In this role, you will:

• Perform adjustments across all dollar amount levels on customer service platforms, specifically by using technical and claims processing expertise.
• Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
• Perform claim re-work calculations.
• Follow through with 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, in order to allocate refund checks.
• Handle telephonic and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure 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 less experienced staff members.
• Utilize all resource materials to manage job responsibilities.
  

Required Qualifications

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

Preferred Qualifications

• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communication, organizational, and interpersonal skills.
• Previous experience with DG system claims processing.

Education

• Associate’s degree or equivalent experience (high school diploma or GED + 2 years of relevant experience).

Anticipated Weekly Hours

40

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

The Senior Claims Benefit Specialist will review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims. They will adjudicate complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. This person will also process provider refunds and returned checks. They also may handle customer service inquiries and problems.

In this role, you will:

• Perform adjustments across all dollar amount levels on customer service platforms, specifically by using technical and claims processing expertise.
• Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
• Perform claim re-work calculations.
• Follow through with 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, in order to allocate refund checks.
• Handle telephonic and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure 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 less experienced staff members.
• Utilize all resource materials to manage job responsibilities.
  

Required Qualifications

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

Preferred Qualifications

• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communication, organizational, and interpersonal skills.
• Previous experience with DG system claims processing.

Education

• Associate’s degree or equivalent experience (high school diploma or GED + 2 years of relevant experience).

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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 07/04/2025

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

About the company

At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.

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