Senior Health Claims & Benefits Specialist

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

Benefits offered by this job

Medical insurance

Dental insurance

Vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking an experienced Claims Processor to review and adjudicate complex medical claims and related refunds. You will use claims processing guidelines, apply medical necessity rules, and handle inquiries while ensuring accurate, compliant payments.

The role requires 2+ years of experience in medical claim processing within a production environment. Strong attention to detail and effective communication are essential for success in a fast-paced team.

Qualifications

• 2+ years of medical claim processing experience.
• Experience in a production environment.
• Proven ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communication, organizational, and interpersonal skills.

Responsibilities

• Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and RX claims per processing guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Apply medical necessity guidelines to determine coverage and verify eligibility.
• Review medical contracts to confirm overpayments and allocate refunds.
• Handle inquiries for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and timely payments per company policies.
• Review related correspondence and assist in claim adjustments.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Job description

CVS Health is seeking an experienced Claims Processor to review and adjudicate complex medical claims and related refunds. You will use claims processing guidelines, apply medical necessity rules, and handle inquiries while ensuring accurate, compliant payments.

The role requires 2+ years of experience in medical claim processing within a production environment. Strong attention to detail and effective communication are essential for success in a fast-paced team.