Senior Medical Claims & Benefits Specialist

CVS Health; Columbia (SC); 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

Other resources, based on eligibility

Job summary

CVS Health in the United States seeks a claims professional to review and adjudicate SF, FI, Reinsurance, and RX claims, process refunds, and handle complex adjustments using guidelines and contracts.

Responsibilities include eligibility verification, applying medical necessity guidelines, addressing inquiries, ensuring compliance, and supporting staff. This full-time role offers health coverage, PTO, retirement options, and wellness programs.

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 adjust SF (self-funded), FI (fully insured), Reinsurance, and RX claims.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems; provide pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and accurate payments; review contract language and provider contracts.
• Review and handle correspondences for adjustments and refunds; may provide shadowing to junior staff.

Skills

Medical claim processing

Production environment

Multitask

Communication skills

Education

High School Diploma or GED

Job description

CVS Health in the United States seeks a claims professional to review and adjudicate SF, FI, Reinsurance, and RX claims, process refunds, and handle complex adjustments using guidelines and contracts.

Responsibilities include eligibility verification, applying medical necessity guidelines, addressing inquiries, ensuring compliance, and supporting staff. This full-time role offers health coverage, PTO, retirement options, and wellness programs.