Senior Claims Benefit Specialist: Impactful Adjudication

CVS Health; Lorida (FL); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health in the United States is seeking a claims processor to review and adjust self-funded, fully insured, reinsurance, and RX claims, including refunds and complex adjudication. The role involves applying medical guidelines, verifying eligibility, and processing inquiries related to pre-approvals or appeals, while ensuring compliance and accurate payments.

The position requires 2+ years in medical claim processing, ability to multitask in a production setting, and strong communication

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 SF, FI, Reinsurance, and RX claims per guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems as needed.
• Perform adjustments across all dollar levels using claims processing expertise.
• Apply medical necessity guidelines and determine coverage.
• Review and interpret contract language for overpayments/refunds.
• Handle pre-approvals, reconsiderations, or appeals by phone or in writing.
• Ensure compliance and proper payments follow company procedures.
• Review related correspondences that may affect claim adjustments.
• May provide job shadowing to less experienced staff.
• Utilize all resources to manage duties.

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health in the United States is seeking a claims processor to review and adjust self-funded, fully insured, reinsurance, and RX claims, including refunds and complex adjudication. The role involves applying medical guidelines, verifying eligibility, and processing inquiries related to pre-approvals or appeals, while ensuring compliance and accurate payments.

The position requires 2+ years in medical claim processing, ability to multitask in a production setting, and strong communication