Senior Health Claims Specialist - Complex Adjudication

CVS Health; Connecticut; On-site; USD 25,000 - 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 full-time Claims Processor in Connecticut to review and adjudicate self-funded, fully insured, reinsurance, and RX claims. The role handles complex inquiries, cost containment, refunds, and appeals while ensuring compliance and accuracy across multiple systems.

Ideal candidates will have 2+ years of medical claim processing experience, strong communication skills, and the ability to manage multiple tasks in a production environment.

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 adjudicate SF (self-funded), FI (fully insured), Reinsurance, and RX claims.
• Perform adjustments across all dollar amount levels on customer service platforms using claims processing expertise.
• Apply medical necessity guidelines and determine coverage with eligibility verification.
• Identify discrepancies and apply cost containment measures to assist claim adjudication.
• Handle overpayments, underpayments, and other irregularities; perform re-work calculations.
• Process complex non-routine Provider Refunds and Returned Checks.
• Review provider contracts to confirm whether a claim is overpaid and allocate refunds.
• Handle telephone and written inquiries related to pre-approvals, reconsiderations, or appeals.
• Ensure compliance requirements are satisfied and all payments follow company procedures.
• Review relevant correspondences that may result in adjustments to claims.
• May provide job shadowing to lesser experienced staff.
• Utilize all resource materials to manage job responsibilities.

Skills

Medical claim processing

Production environment

Multitasking

Communication

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health is seeking a full-time Claims Processor in Connecticut to review and adjudicate self-funded, fully insured, reinsurance, and RX claims. The role handles complex inquiries, cost containment, refunds, and appeals while ensuring compliance and accuracy across multiple systems.

Ideal candidates will have 2+ years of medical claim processing experience, strong communication skills, and the ability to manage multiple tasks in a production environment.