Senior Claims & Benefits Architect

CVS Health; Providence (RI); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health is seeking a claims processor to review and adjudicate various self-funded and insured claims, including RX, with duties ranging from refunds to cost containment and compliance. The role requires handling inquiries, pre-approvals, and appeals while applying medical necessity guidelines.

The position is full-time with 40 hours weekly, based in the Providence area. CVS Health offers a comprehensive benefits package and opportunities for professional growth.

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 adjudicate SF, FI, Reinsurance, and RX claims in accordance with processing guidelines.
• Process provider refunds and returned checks; handle complex non-routine refunds.
• Apply medical necessity guidelines, determine coverage, verify eligibility and identify discrepancies.
• Perform claim re-work calculations and follow through on overpayments/underpayments.
• Review provider contracts to determine if claims are overpaid and handle related refunds.
• Handle inquiries for pre-approvals/pre-authorizations, reconsiderations, or appeals and ensure compliance.
• Provide guidance and possibly job shadowing to lesser experienced staff.

Skills

Medical claims 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 various self-funded and insured claims, including RX, with duties ranging from refunds to cost containment and compliance. The role requires handling inquiries, pre-approvals, and appeals while applying medical necessity guidelines.

The position is full-time with 40 hours weekly, based in the Providence area. CVS Health offers a comprehensive benefits package and opportunities for professional growth.