Senior Health Claims Specialist — Complex Adjudication

CVS Health; Wyoming (MI); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Health benefits

Bonus program

Job summary

CVS Health is seeking a detail-oriented Claims Processor to review and adjudicate SF, FI, Reinsurance, and RX claims. You will process refunds, handle inquiries, and apply medical necessity guidelines to determine coverage while ensuring compliance with company practices.

Ideal candidates have 2+ years of claims processing experience in a production setting, with strong communication and organizational skills to manage multiple tasks accurately and efficiently.

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 claims: self-funded, fully insured, reinsurance, and RX.
• Process provider refunds and returned checks.
• Handle customer service inquiries related to pre-approvals and appeals.
• Apply medical necessity guidelines and verify eligibility to determine coverage.
• Perform claim re-work calculations and resolve over/underpayments.
• Ensure all payments comply with company practices and procedures.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Organizational skills

Education

High School Diploma or GED

Job description

CVS Health is seeking a detail-oriented Claims Processor to review and adjudicate SF, FI, Reinsurance, and RX claims. You will process refunds, handle inquiries, and apply medical necessity guidelines to determine coverage while ensuring compliance with company practices.

Ideal candidates have 2+ years of claims processing experience in a production setting, with strong communication and organizational skills to manage multiple tasks accurately and efficiently.