Senior Healthcare Claims Specialist

CVS Health; Yuma (AZ); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Benefits package

Bonus eligibility

Job summary

CVS Health is seeking a claims processor to review and adjudicate SF, FI, reinsurance, and RX claims, ensuring compliance with guidelines. This role handles complex adjustments, refunds, and inquiries in a fast-paced production environment.

You will apply medical necessity guidelines, determine coverage, verify eligibility, and process overpayments, with a focus on accuracy and timely resolution. This full-time position offers comprehensive benefits, and opportunities for professional growth.

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 self-funded, fully insured, reinsurance, and RX claims per guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across dollar amounts on claims processing platforms.
• Apply medical necessity guidelines to determine coverage and eligibility.
• Review contract language to verify overpayments and allocate refunds.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Tools

DG System

Job description

CVS Health is seeking a claims processor to review and adjudicate SF, FI, reinsurance, and RX claims, ensuring compliance with guidelines. This role handles complex adjustments, refunds, and inquiries in a fast-paced production environment.

You will apply medical necessity guidelines, determine coverage, verify eligibility, and process overpayments, with a focus on accuracy and timely resolution. This full-time position offers comprehensive benefits, and opportunities for professional growth.