Senior Claims Benefit Specialist – Full-Time with Benefits

CVS Health; Maine; Presencial; USD 25.000 - 58.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Descripción de la vacante

CVS Health is seeking a full-time Medical Claims Processor to review and adjudicate self-funded and fully insured claims, process provider refunds, and handle complex inquiries. This role requires meticulous attention to guidelines and the ability to perform in a production environment.

You will verify eligibility, apply medical necessity guidelines, perform claim re-work, and ensure payments comply with company procedures. The position offers comprehensive benefits and bonus eligibility.

Formación

• 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.

Responsabilidades

• Review and adjudicate SF, FI, Reinsurance, and RX claims per processing guidelines.
• 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.
• Perform claim re-work calculations and follow up on overpayments/underpayments.
• Review provider contracts to determine overpayments and allocate refunds.
• Address requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance requirements are satisfied and payments follow procedures.
• Review relevant correspondences and potentially provide shadowing to junior staff.

Conocimientos

Medical claim processing

Production environment

Multitasking

Communication skills

Educación

High School Diploma or GED

Associate degree preferred

Descripción del empleo

CVS Health is seeking a full-time Medical Claims Processor to review and adjudicate self-funded and fully insured claims, process provider refunds, and handle complex inquiries. This role requires meticulous attention to guidelines and the ability to perform in a production environment.

You will verify eligibility, apply medical necessity guidelines, perform claim re-work, and ensure payments comply with company procedures. The position offers comprehensive benefits and bonus eligibility.