Senior Claims & Benefits Specialist — Shape Health

CVS Health

North Carolina

Sur place

USD 25 000 - 58 000

Plein temps

Il y a 5 jours

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Avantages offerts par ce poste

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Résumé du poste

CVS Health in the United States is seeking a Claims Processor to review and adjudicate SF, FI, Reinsurance, and RX claims, applying medical necessity guidelines and ensuring accurate payments. You will handle refunds, complex inquiries, and provider negotiations while maintaining compliance in a fast-paced production setting.

This full-time role offers a base pay range with comprehensive benefits and opportunities to collaborate across teams to improve claim outcomes.

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.

Responsabilités

Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and RX claims.
Process provider refunds and returned checks.
Handle customer service inquiries and problems.
Perform claim adjustments across all dollar levels on claims platforms.
Apply medical necessity guidelines and determine coverage; verify eligibility.
Review contract language to confirm overpayments and allocate refunds.
Handle pre-authorizations, reconsiderations, or appeals inquiries.
Ensure compliance with company procedures and timely payments.
Review relevant correspondences and support team workflows.