Senior Health Claims & Benefits Specialist

CVS Health; Milton (MA); On-site; USD 15,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a claims specialist to review and adjudicate complex medical claims, process refunds and provider refunds, and respond to customer inquiries. The role requires applying medical necessity guidelines, verifying eligibility, and ensuring compliance with company procedures.

The position is full-time, on-site in a healthcare operations setting, offering a base hourly pay range and eligibility for CVS Health bonus programs.

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 adjust SF (self-funded), FI (fully insured), Reinsurance, and/or 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 amount level on customer service platforms by using technical and claims processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.

Skills

Claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Job description

CVS Health is seeking a claims specialist to review and adjudicate complex medical claims, process refunds and provider refunds, and respond to customer inquiries. The role requires applying medical necessity guidelines, verifying eligibility, and ensuring compliance with company procedures.

The position is full-time, on-site in a healthcare operations setting, offering a base hourly pay range and eligibility for CVS Health bonus programs.