Senior Health Claims Specialist — Complex Claims Expert

CVS Health; Sacramento (CA); 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 in California is seeking a dedicated Claims Processor to review and adjust SF (self-funded), FI (fully insured), Reinsurance, and RX claims while handling complex inquiries and refunds. You will apply medical necessity guidelines, perform adjustments, and ensure compliance, supporting customer service needs.

The role requires attention to detail and the ability to manage multiple tasks in a fast-paced 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 adjust SF (self-funded), FI (fully insured), Reinsurance, and RX claims.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across all dollar amount levels on claims processing platforms.
• Apply medical necessity guidelines and verify eligibility.
• Follow through on claim overpayments and underpayments.
• Process complex non-routine provider refunds and returned checks.
• Review medical contracts to confirm overpayments and allocate refunds.
• Address requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and proper payments per company procedures.

Skills

Medical claim processing

Production environment

Multitasking

Communication

Education

High School Diploma or GED

Associate degree preferred

Tools

DG system claims processing

Claims processing software

Job description

CVS Health in California is seeking a dedicated Claims Processor to review and adjust SF (self-funded), FI (fully insured), Reinsurance, and RX claims while handling complex inquiries and refunds. You will apply medical necessity guidelines, perform adjustments, and ensure compliance, supporting customer service needs.

The role requires attention to detail and the ability to manage multiple tasks in a fast-paced environment.