Senior Medical Claims & Benefit Specialist (Remote)

CVS Health; Idaho; Híbrido; USD 26.000 - 58.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Descripción de la vacante

CVS Health in Idaho is seeking a Claims Adjudication specialist who reviews and adjudicates complex medical claims under established guidelines. You will act as SME by coaching colleagues and guiding escalated issues, supporting customer service to ensure a positive member experience.

The role emphasizes applying medical necessity guidelines, verifying eligibility, identifying discrepancies, and ensuring payments align with company policies.

Formación

• Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator.
• Proven success working in a high‑volume, production‑driven environment.
• Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail.
• Self-Funding experience (preferred)
• DG system knowledge (preferred)

Responsabilidades

• Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication.
• Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures.
• Identifies and reports potential overpayments, underpayments, and other claim irregularities.
• Performs claim rework calculations as needed.
• Trains and mentors as needed to enhance team performance and technical proficiency.
• Conducts outbound calls to obtain required information for claims or reconsideration requests.

Conocimientos

Medical claims processing

Multi‑tasking

Attention to detail

Educación

High School Diploma

Associates degree or equivalent work experience

Herramientas

DG system knowledge

Descripción del empleo

CVS Health in Idaho is seeking a Claims Adjudication specialist who reviews and adjudicates complex medical claims under established guidelines. You will act as SME by coaching colleagues and guiding escalated issues, supporting customer service to ensure a positive member experience.

The role emphasizes applying medical necessity guidelines, verifying eligibility, identifying discrepancies, and ensuring payments align with company policies.