Senior Health Claims Benefit Specialist - Adjudication

CVS Health; Kansas City (MO); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health is hiring for a full-time claims processor role in the United States. You will review and adjudicate self-funded, fully insured, and RX claims, process refunds, and apply medical necessity guidelines to determine coverage.

The job involves handling complex inquiries, pre-approvals, reconsiderations, and appeals with a focus on accuracy and efficiency. The position requires 2+ years of medical claim processing experience, experience in a production environment, 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 adjudicate SF (self-funded), FI (fully insured), Reinsurance, and 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 amounts on customer service platforms using technical and claims processing expertise.
• Review and interpret medical contract language to confirm overpayments and allocate refunds; handle inquiries for pre-approvals/pre-authorizations, reconsiderations, or appeals.

Skills

Medical claim processing

Production environment

Multitask effectively

Communication skills

Education

High School Diploma or GED

Job description

CVS Health is hiring for a full-time claims processor role in the United States. You will review and adjudicate self-funded, fully insured, and RX claims, process refunds, and apply medical necessity guidelines to determine coverage.

The job involves handling complex inquiries, pre-approvals, reconsiderations, and appeals with a focus on accuracy and efficiency. The position requires 2+ years of medical claim processing experience, experience in a production environment, and strong communication