Senior Medical Claims & Benefits Specialist

CVS Health; Clayton (NC); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Comprehensive benefits package

Job summary

CVS Health is seeking a claims processor to review and adjudicate medical and RX claims, handle refunds and inquiries, and ensure accurate processing in a fast-paced environment.

Ideal candidates have 2+ years of claim processing experience, strong organizational skills, and the ability to manage multiple tasks while maintaining accuracy and compliance. Full-time role with benefits in NC.

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 RX claims.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems.
• Perform adjustments across all dollar amount levels on customer service platforms.
• Apply medical necessity guidelines and determine coverage.
• Review and interpret medical contract language to confirm overpayments.
• Ensure compliance with all payments and company procedures.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Tools

DG system claims processing

Job description

CVS Health is seeking a claims processor to review and adjudicate medical and RX claims, handle refunds and inquiries, and ensure accurate processing in a fast-paced environment.

Ideal candidates have 2+ years of claim processing experience, strong organizational skills, and the ability to manage multiple tasks while maintaining accuracy and compliance. Full-time role with benefits in NC.