Senior Health Claims & Benefits Specialist

CVS Health; Phoenix (AZ); Vor Ort; USD 15.000 - 58.000; Vollzeit

Zusammenfassung

CVS Health in Phoenix is seeking a claims processor to review and adjudicate SF (self-funded), FI (fully insured), Reinsurance, and RX claims, ensuring compliance with processing guidelines. The role handles complex inquiries, refunds, and provider issues in a fast-paced production environment.

We value thoroughness, accuracy, and strong communication as you review contracts, verify eligibility, apply cost containment measures, and support customers through pre-approvals and appeals.

Qualifikationen

• 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.

Aufgaben

• 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.
• Performs claim re-work calculations.
• Follow through completion of claim overpayments, underpayments, and any other irregularities.
• Process complex non-routine Provider Refunds and Returned Checks.
• Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks.
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures.
• Review and handle relevant correspondences assigned to the team that may result in adjustment to claims.
• May provide job shadowing to lesser experience staff.
• Utilize all resource materials to manage job responsibilities

Kenntnisse

Medical claims processing

Production environment experience

Multitasking

Communication skills

Ausbildung

High School Diploma or GED

Associate degree preferred

Jobbeschreibung

CVS Health in Phoenix is seeking a claims processor to review and adjudicate SF (self-funded), FI (fully insured), Reinsurance, and RX claims, ensuring compliance with processing guidelines. The role handles complex inquiries, refunds, and provider issues in a fast-paced production environment.

We value thoroughness, accuracy, and strong communication as you review contracts, verify eligibility, apply cost containment measures, and support customers through pre-approvals and appeals.