Senior Medical Claims & Benefits Specialist

CVS Health; Dover (DE); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health is seeking a claims processor to review and adjust self-funded, fully insured, and reinsurance claims, including RX claims. You will handle complex adjustments, refunds, and inquiries while applying medical necessity guidelines and contract language.

The role requires accuracy, strong organizational skills, and the ability to work in a fast-paced production environment. It offers full-time hours with comprehensive benefits and eligibility for CVS Health bonus programs.

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, FI, Reinsurance, and RX claims.
• Process provider refunds and returned checks.
• Handle customer service inquiries related to pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Follow compliance requirements and ensure payments align with procedures.
• Review and interpret medical contracts to determine overpayments or refunds.
• 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 is seeking a claims processor to review and adjust self-funded, fully insured, and reinsurance claims, including RX claims. You will handle complex adjustments, refunds, and inquiries while applying medical necessity guidelines and contract language.

The role requires accuracy, strong organizational skills, and the ability to work in a fast-paced production environment. It offers full-time hours with comprehensive benefits and eligibility for CVS Health bonus programs.