Senior Health Claims Benefit Specialist — Complex Claims

CVS Health; Denver (CO); Sur place; USD 25 000 - 58 000; Plein temps

Avantages offerts par ce poste

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Résumé du poste

CVS Health in Denver, CO, is seeking a Claims Adjudicator to review and adjust self-funded, fully insured, and RX claims, ensuring compliance and accurate payments. The role handles complex inquiries, refunds, and provider communications while upholding quality standards.

You’ll work in a production environment with 40 hours weekly, leveraging claims processing knowledge, medical policy guidelines, and provider contracts to determine coverage and manage overpayments or underpayments.

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, FI, Reinsurance, and RX claims per guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across all dollar amounts on claims processing platforms.
• Apply medical necessity guidelines to determine coverage and verify eligibility.
• Identify discrepancies and apply cost containment measures in adjudication.
• Review overpayments/underpayments and resolve irregularities.
• Process complex non-routine provider refunds and returned checks.
• Interpret medical contract language to confirm overpayments and allocate refunds.
• Handle inquiries related to pre-approvals, reconsiderations, or appeals.

Connaissances

Medical claim processing

Production environment experience

Multi-tasking

Communication skills

Formation

High School Diploma or GED

Associate degree preferred

Description du poste

CVS Health in Denver, CO, is seeking a Claims Adjudicator to review and adjust self-funded, fully insured, and RX claims, ensuring compliance and accurate payments. The role handles complex inquiries, refunds, and provider communications while upholding quality standards.

You’ll work in a production environment with 40 hours weekly, leveraging claims processing knowledge, medical policy guidelines, and provider contracts to determine coverage and manage overpayments or underpayments.