Senior Health Claims Specialist: Complex Adjudication

CVS Health; Arizona; On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Retirement plan

Paid time off

Bonus program

Job summary

CVS Health is looking for a claims processing professional to review and adjudicate self-funded, fully insured, and RX claims, including complex cases. You will process refunds, respond to customer inquiries, and ensure compliance with company procedures.

The role emphasizes accuracy, efficiency, and adherence to medical necessity guidelines in a fast-paced environment. This full-time position offers a base pay range shown 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, FI, Reinsurance, and RX claims per guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments on all dollar amount levels on claims platforms.
• Apply medical necessity guidelines and determine coverage.
• Complete eligibility verification and apply cost containment measures.
• Perform claim re-work calculations.
• Manage overpayments/underpayments and irregularities.
• Process complex provider refunds and returned checks.
• Interpret medical contract language to confirm overpayments.
• Handle inquiries regarding pre-approvals, reconsiderations, or appeals.
• Ensure compliance and proper payments.
• Review related correspondences and assist junior staff.

Skills

Medical claims processing

Production environment experience

Multi-tasking

Communication skills

Education

High School Diploma or GED

Job description

CVS Health is looking for a claims processing professional to review and adjudicate self-funded, fully insured, and RX claims, including complex cases. You will process refunds, respond to customer inquiries, and ensure compliance with company procedures.

The role emphasizes accuracy, efficiency, and adherence to medical necessity guidelines in a fast-paced environment. This full-time position offers a base pay range shown and eligibility for CVS Health bonus programs.