Senior Healthcare Claims & Benefit Specialist

CVS Health; Guin (AL); On-site; USD 26,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health is seeking an experienced claims processor to review and adjudicate self-funded and fully insured claims, including RX, in a full-time role. You will handle refunds, oversee complex claim adjustments, and ensure compliance with processing guidelines.

The position requires 2+ years in medical claim processing, strong communication and organizational skills, and the ability to manage multiple tasks in a production environment.

Qualifications

• Must have strong communication and organizational abilities.
• Experience handling multiple assignments in a production environment.
• Ability to work in a fast-paced healthcare claims setting.

Responsibilities

• Adjust claims across all dollar levels using processing expertise.
• Apply medical necessity guidelines and determine coverage/eligibility.
• Process provider refunds and returned checks.
• Handle customer service inquiries related to claims.
• Perform claim re-work calculations and address overpayments/underpayments.
• Review contract language to confirm overpayments and allocate refunds.
• Handle pre-approvals/pre-authorizations, reconsiderations, or appeals inquiries.
• Ensure payments meet company policies and compliance.
• Review correspondences that may affect claim adjustments.
• May provide job shadowing to less experienced staff.
• Utilize all resources to manage responsibilities.

Skills

Effective communication

Organizational skills

Interpersonal skills

Ability to multitask

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health is seeking an experienced claims processor to review and adjudicate self-funded and fully insured claims, including RX, in a full-time role. You will handle refunds, oversee complex claim adjustments, and ensure compliance with processing guidelines.

The position requires 2+ years in medical claim processing, strong communication and organizational skills, and the ability to manage multiple tasks in a production environment.