Senior Medical Claims Benefit Specialist — Remote

CVS Health; Vermont; Hybrid; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision coverage

Paid time off

Retirement plan

Wellness programs

Job summary

CVS Health is seeking a Claims Adjudicator to review and adjudicate complex medical claims with precision. You will apply medical necessity guidelines, verify coverage, and resolve issues to ensure a positive member experience.

You will work in a high-volume environment, handle escalations, and mentor teammates while maintaining accuracy. A High School Diploma is required, with preferred Associate’s degree or equivalent experience.

Qualifications

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

Responsibilities

• Review and adjudicate complex medical claims following guidelines.
• Apply medical necessity guidelines and verify eligibility.
• Identify discrepancies, cost-containment opportunities, and ensure regulatory compliance.
• Mentor and train teammates to improve performance and technical skills.
• Conduct outbound calls to obtain information for claims or reconsideration requests.

Skills

Medical claim processing

Attention to detail

Multitasking

Education

High School Diploma

Associate's degree or equivalent work experience

Job description

CVS Health is seeking a Claims Adjudicator to review and adjudicate complex medical claims with precision. You will apply medical necessity guidelines, verify coverage, and resolve issues to ensure a positive member experience.

You will work in a high-volume environment, handle escalations, and mentor teammates while maintaining accuracy. A High School Diploma is required, with preferred Associate’s degree or equivalent experience.