Senior Medical Claims & Adjudication Specialist

CVS Health; Clayton (NM); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Bonus eligibility

Comprehensive benefits

Job summary

CVS Health in the United States is seeking a claims processor to adjudicate complex medical claims across self-funded, fully insured, and RX programs. The role handles refunds, refunds checks, and may respond to customer inquiries while applying medical necessity guidelines to determine coverage.

The position requires approximately 2+ years of experience in medical claim processing, working in a production setting, and strong communication skills.

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/or RX claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.
• Process provider refunds and returned checks.
• May handle customer service inquiries and problems.
• Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
• Performs claim re-work calculations.
• Follow through completion of claim overpayments, underpayments, and any other irregularities.
• Process complex non-routine Provider Refunds and Returned Checks.
• Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks.
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures.
• Review and handle relevant correspondences assigned to the team that may result in adjustment to claims.
• May provide job shadowing to lesser experience staff.
• Utilize all resource materials to manage job responsibilities

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health in the United States is seeking a claims processor to adjudicate complex medical claims across self-funded, fully insured, and RX programs. The role handles refunds, refunds checks, and may respond to customer inquiries while applying medical necessity guidelines to determine coverage.

The position requires approximately 2+ years of experience in medical claim processing, working in a production setting, and strong communication skills.