Senior Medical Claims & Benefit Specialist

CVS Health Corporation; Town of Florida (NY); Hybrid; USD 53,010,000 - 121,350,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health Corporation in New York state is seeking a claims adjudicator to review and adjudicate complex medical claims, applying guidelines and ensuring accuracy in processing. This role supports customer service operations and helps deliver a positive member experience.

The incumbent will coach teammates, assist with escalated issues, and ensure compliance with regulatory requirements while maintaining high performance in a fast-paced environment.

Qualifications

• Minimum 18 months of medical claim processing experience with a health insurance payor or TPA.
• Experience in a high-volume, production-driven environment.
• Ability to manage multiple assignments with accuracy and efficiency.

Responsibilities

• Review and adjudicate complex or high‑level medical claims.
• Provide coaching and guidance on escalated issues to teammates.
• Support customer service by addressing inquiries and resolving issues to ensure a positive member experience.
• Apply medical necessity guidelines, determine coverage, verify eligibility, and identify discrepancies.
• Ensure payments align with company policies and procedures and identify potential overpayments or underpayments.
• Perform claim rework calculations as needed.
• Conduct outbound calls to obtain required information for claims or reconsideration requests.

Skills

Medical claim processing

Attention to detail

Time management

Multi-tasking

Education

High School Diploma

Associate degree or equivalent experience

Tools

DG system knowledge

Job description

CVS Health Corporation in New York state is seeking a claims adjudicator to review and adjudicate complex medical claims, applying guidelines and ensuring accuracy in processing. This role supports customer service operations and helps deliver a positive member experience.

The incumbent will coach teammates, assist with escalated issues, and ensure compliance with regulatory requirements while maintaining high performance in a fast-paced environment.