Senior Medical Claims & Benefits Specialist

CVS Health; Harrisburg (Dauphin County); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health in the United States is seeking a full‑time claims processor to review and adjust SF, FI, Reinsurance, and RX claims. The role handles refunds, customer inquiries, and complex adjudication using guidelines and contracts.

You will perform adjustments, verify eligibility, and ensure compliant payments while supporting colleagues and contributing to a high‑quality health experience.

Qualifications

• 2+ years 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 and problems.
• Perform adjustments across all dollar levels on claims platforms.
• Apply medical necessity guidelines to determine coverage.
• Manage claim overpayments, underpayments, and irregularities.
• Review provider contracts to confirm overpayments and allocate refunds.
• Handle inquiries for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and accurate payments according to company procedures.
• Review relevant correspondences that may affect claim adjustments.

Skills

Medical claim processing

Production environment

Multitasking

Communication skills

Education

High School Diploma or GED

Job description

CVS Health in the United States is seeking a full‑time claims processor to review and adjust SF, FI, Reinsurance, and RX claims. The role handles refunds, customer inquiries, and complex adjudication using guidelines and contracts.

You will perform adjustments, verify eligibility, and ensure compliant payments while supporting colleagues and contributing to a high‑quality health experience.