Senior Claims Benefit Specialist: Complex Health Claims Expert

CVS Health; Colorado Springs (CO); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, vision

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a claims processor to review and adjudicate self-funded, fully insured, reinsurance, and RX claims. You will handle refunds, ensure compliance, and apply medical necessity guidelines to determine coverage.

The role requires 2+ years of medical claim processing experience, ability to manage multiple tasks, and strong communication skills in a production environment. Full-time, 40 hours/week in Colorado Springs.

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 self-funded, fully insured, reinsurance, and RX claims.
• Process provider refunds and returned checks.
• Perform claim adjustments across all dollar amount levels on claims platforms.
• Apply medical necessity guidelines, determine coverage, and verify eligibility.
• Review and handle pre-approvals, reconsiderations, or appeals; ensure compliance and proper payments.
• May provide job shadowing to lesser experience staff.
• Utilize all resource materials to manage job responsibilities.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health is seeking a claims processor to review and adjudicate self-funded, fully insured, reinsurance, and RX claims. You will handle refunds, ensure compliance, and apply medical necessity guidelines to determine coverage.

The role requires 2+ years of medical claim processing experience, ability to manage multiple tasks, and strong communication skills in a production environment. Full-time, 40 hours/week in Colorado Springs.