Senior Health Claims Specialist – Complex Adjudication

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

Benefits offered by this job

Medical benefits

Dental benefits

Retirement plan

Job summary

CVS Health is seeking a claims processor to review and adjust self-funded, fully insured, reinsurance, and RX claims, including refunds and complex inquiries. You will apply medical necessity guidelines and verify coverage to ensure accurate payments across various claim scenarios.

The role requires 2+ years of medical claim processing experience in a production environment, plus strong communication, organizational, and interpersonal skills. Full-time position with competitive benefits.

Qualifications

• 2+ years of 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.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across all dollar amount levels on customer service platforms.
• Apply medical necessity guidelines, determine coverage, verify eligibility, and identify discrepancies.
• Review and interpret medical contract language to confirm whether a claim is overpaid and allocate refund checks.
• Handle pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure all compliance requirements are satisfied and that all payments are made following company practices.

Skills

Communication skills

Organizational skills

Interpersonal skills

Education

High School diploma or GED

Associate degree preferred

Tools

DG system claims processing

Job description

CVS Health is seeking a claims processor to review and adjust self-funded, fully insured, reinsurance, and RX claims, including refunds and complex inquiries. You will apply medical necessity guidelines and verify coverage to ensure accurate payments across various claim scenarios.

The role requires 2+ years of medical claim processing experience in a production environment, plus strong communication, organizational, and interpersonal skills. Full-time position with competitive benefits.