Senior Medical Claims & Benefits Specialist

CVS Health; Central City (KY); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Bonus or incentive program

Job summary

CVS Health in the United States is seeking a claims processor to adjudicate complex medical claims and manage refunds, ensuring accuracy and compliance. The role involves supporting patient inquiries, applying guidelines, and working in a production environment with attention to detail.

The ideal candidate has 2+ years of claim processing experience, strong communication skills, and the ability to handle multiple priorities while maintaining quality and efficiency.

Qualifications

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

Responsibilities

• Review and adjudicate SF, FI, Reinsurance, and RX claims per guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems as needed.
• Apply medical necessity guidelines and determine coverage.
• Perform claim re-work calculations and review over/underpayments.
• Ensure compliance and accurate payments per company procedures.
• Assist with pre-approvals/pre-authorizations and appeals as required.
• Provide job shadowing to less experienced staff.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health in the United States is seeking a claims processor to adjudicate complex medical claims and manage refunds, ensuring accuracy and compliance. The role involves supporting patient inquiries, applying guidelines, and working in a production environment with attention to detail.

The ideal candidate has 2+ years of claim processing experience, strong communication skills, and the ability to handle multiple priorities while maintaining quality and efficiency.