Senior Medical Claims Adjudication Specialist

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

Job summary

CVS Health in Alabama is seeking an experienced claims processor to review and adjudicate self-funded, fully insured, and RX claims, handling complex cases with processing guidelines guidance. You will manage refunds, provider interactions, and inquiries in a fast-paced setting.

The role emphasizes accuracy, compliance, and efficient communication across teams, with full-time hours and a comprehensive benefits package.

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 processing guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across all dollar amounts on service platforms.
• Apply medical necessity guidelines to determine coverage and verify eligibility.
• Identify discrepancies and apply cost containment measures in adjudication.
• Handle pre-approvals/pre-authorizations, reconsiderations, or appeals inquiries.
• Ensure compliance and correct payments per company procedures.
• Review relevant correspondences and adjust claims as needed.
• May provide job shadowing to less experienced staff.

Skills

Claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health in Alabama is seeking an experienced claims processor to review and adjudicate self-funded, fully insured, and RX claims, handling complex cases with processing guidelines guidance. You will manage refunds, provider interactions, and inquiries in a fast-paced setting.

The role emphasizes accuracy, compliance, and efficient communication across teams, with full-time hours and a comprehensive benefits package.