Senior Claims Benefit Specialist — Health Claims Expert

CVS Health; Idaho; Presencial; USD 25 000 - 58 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement options

Resumo da oferta

CVS Health is seeking a claims processor to review and adjudicate complex medical claims across self-funded, fully insured, and RX lines. You will process refunds, resolve customer inquiries, and apply medical necessity guidelines to determine coverage.

The role requires accurate handling of high-volume tasks and strong collaboration with teammates in a fast-paced environment. The position emphasizes accuracy, efficiency, and adherence to compliance, with typical full-time hours and a

Qualificações

• ~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.

Responsabilidades

• 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

Conhecimentos

Claims processing

Production environment

Multitasking

Communication

Organization

Formação académica

High School Diploma or GED

Associate degree preferred

Ferramentas

DG system claims processing

Descrição da oferta de emprego

CVS Health is seeking a claims processor to review and adjudicate complex medical claims across self-funded, fully insured, and RX lines. You will process refunds, resolve customer inquiries, and apply medical necessity guidelines to determine coverage.

The role requires accurate handling of high-volume tasks and strong collaboration with teammates in a fast-paced environment. The position emphasizes accuracy, efficiency, and adherence to compliance, with typical full-time hours and a