Senior Claims Benefit Specialist - Remote

CVS Pharmacy; Saint Paul (MN); Remote; Full time

Job summary

A leading health solutions company is seeking a Claims Specialist to review and adjudicate complex claims. The role involves training junior staff and ensuring compliance with processing guidelines. Ideal candidates will have experience in medical claim processing and a strong ability to manage multiple tasks efficiently.

Benefits

401(k) plan with matching contributions

Affordable medical plan options

Employee stock purchase plan

Wellness screenings

Tuition assistance

Qualifications

• 2+ years medical claim processing experience.
• 1-2 years experience in a production/metrics based environment.

Responsibilities

• Reviews and adjudicates complex claims according to guidelines.
• Handles phone and written inquiries related to pre-approval requests.
• Trains and mentors junior staff.

Skills

Medical Claim Processing

Multi-tasking

Education

High School Diploma

Associates Degree

Job description

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary
Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems.

Additional Responsibilities

• Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment. measures to assist in the claim adjudication process.
• Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.
• Insures all compliance requirements are satisfied and all payments are made against company practices and procedures.
• Identifies and reports possible claim overpayments, underpayments and any other irregularities.
• Performs claim rework calculations.
• Distributes work assignment daily to junior staff.
• Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration.

Required Qualifications

• 2+ years medical claim processing experience.
• 1-2 years Experience in a production/ metrics based environment
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Preferred Qualifications

• Self-Funding experience
• DG system knowledge

Education

• High School Diploma required
• Preferred Associates degree or equivalent work experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$18.50 - $38.82

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visithttps://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 05/21/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.