Senior Claims Benefit Specialist: Complex Adjudication

CVS Health; Virginia; On-site; USD 26,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health in the United States seeks an experienced claims processor to review and adjudicate self-funded, fully insured, and RX claims, handle provider refunds, and respond to related customer inquiries. The role requires applying medical necessity guidelines, verifying eligibility, and ensuring accurate adjudication.

Candidates should have 2+ years in medical claim processing, experience in a production setting, and strong organizational and communication skills.

Qualifications

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

Responsibilities

• Review and adjudicate SF (self-funded), FI (fully insured), Reinsurance, and RX claims.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across dollar amounts on claims processing platforms.
• Apply medical necessity guidelines and verify eligibility; identify discrepancies and apply cost containment measures.
• Review and interpret medical contract language to confirm overpayments and allocate refunds.
• Handle pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and proper payments per company policy.
• Review correspondences that may result in claim adjustments.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health in the United States seeks an experienced claims processor to review and adjudicate self-funded, fully insured, and RX claims, handle provider refunds, and respond to related customer inquiries. The role requires applying medical necessity guidelines, verifying eligibility, and ensuring accurate adjudication.

Candidates should have 2+ years in medical claim processing, experience in a production setting, and strong organizational and communication skills.