Senior Health Claims Specialist: Complex Claims Expert

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

Benefits offered by this job

Comprehensive benefits

Bonuses & incentives

Job summary

CVS Health in Florida is seeking a claims processor to review and adjudicate self-funded, fully insured, and RX claims, process refunds, and respond to customer inquiries. This role sits in a high-volume production environment requiring accuracy and efficiency.

With 2+ years of medical claim processing experience and strong communication skills, you will manage multiple tasks while ensuring compliance and quality in payments.

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 amounts using claims processing systems.
• Apply medical necessity guidelines and verify eligibility while applying cost containment measures.
• Review and interpret medical contract language to determine overpayments/refunds.
• Handle pre-approvals/pre-authorizations, reconsiderations, or appeals inquiries.
• Ensure compliance and proper payment processing.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Job description

CVS Health in Florida is seeking a claims processor to review and adjudicate self-funded, fully insured, and RX claims, process refunds, and respond to customer inquiries. This role sits in a high-volume production environment requiring accuracy and efficiency.

With 2+ years of medical claim processing experience and strong communication skills, you will manage multiple tasks while ensuring compliance and quality in payments.