Senior Medical Claims & Benefits Specialist

CVS Health; Beryl (WV); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Bonus program

Comprehensive benefits package

Paid time off

Retirement savings options

Job summary

CVS Health is seeking an experienced claims processor to review and adjudicate self-funded, fully insured, and RX claims. The role involves processing provider refunds and returned checks, handling related inquiries, and ensuring compliance with processing guidelines.

You will apply medical necessity guidelines, verify eligibility, identify discrepancies, and implement cost containment measures to assist in adjudication. Strong multitasking and effective communication are essential.

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 in accordance with processing guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems as needed.
• Perform adjustments across dollar amounts using claims processing expertise.
• Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and apply cost containment measures.
• Perform claim re-work calculations and follow through with overpayments/underpayments.

Skills

Medical claims processing

Customer service

Communication

Multitasking

Education

High School Diploma

Tools

DG system

Job description

CVS Health is seeking an experienced claims processor to review and adjudicate self-funded, fully insured, and RX claims. The role involves processing provider refunds and returned checks, handling related inquiries, and ensuring compliance with processing guidelines.

You will apply medical necessity guidelines, verify eligibility, identify discrepancies, and implement cost containment measures to assist in adjudication. Strong multitasking and effective communication are essential.