Senior Medical Claims & Benefits Specialist

CVS Health; California; On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health in California seeks a full-time Claims Processor to review and adjudicate self-funded, fully insured, and RX claims, ensuring compliance and accurate payments. You will handle provider refunds, refunds checks, and related customer inquiries, applying medical necessity guidelines and cost containment measures.

The role involves multi-tasking across complex claims, supporting junior staff, and providing timely responses to pre-approvals, reconsiderations, or appeals as needed.

Qualifications

• 2+ years of medical claim processing experience.
• Experience in a production environment.
• Ability to handle multiple assignments accurately and efficiently.
• Effective communication, organizational, and interpersonal skills.

Responsibilities

• Review and adjust SF, FI, Reinsurance, and RX claims per guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries related to claims.
• Perform claim adjustments and re-work calculations.
• Ensure compliance and accurate payments.
• Review correspondence affecting claims and assist junior staff.

Skills

Medical claim processing

Production environment

Communication skills

Organizational skills

Interpersonal skills

Education

High School Diploma or GED

Job description

CVS Health in California seeks a full-time Claims Processor to review and adjudicate self-funded, fully insured, and RX claims, ensuring compliance and accurate payments. You will handle provider refunds, refunds checks, and related customer inquiries, applying medical necessity guidelines and cost containment measures.

The role involves multi-tasking across complex claims, supporting junior staff, and providing timely responses to pre-approvals, reconsiderations, or appeals as needed.