Senior Medical Claims & Benefits Specialist

CVS Health; Massachusetts; Presencial; USD 25.000 - 58.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

Dental insurance

Vision coverage

Paid time off

Wellness programs

Descripción de la vacante

CVS Health in Massachusetts is seeking an experienced Medical Claims Processor to review and adjudicate self-funded, fully insured, and RX claims. You will handle complex cases, verify eligibility, and apply medical necessity guidelines to determine coverage.

The role involves processing refunds, handling inquiries, and ensuring compliance while working in a production environment. Benefits include health, dental, and vision coverage, PTO, and wellness programs.

Formación

• Approximately 2+ years of medical claim processing experience.
• Experience in a production environment.
• Ability to manage multiple assignments accurately and efficiently.
• Effective written and verbal communication skills.

Responsabilidades

• Review and adjust SF, FI, Reinsurance, and RX claims according to guidelines.
• Process provider refunds and returned checks.
• Handle customer service inquiries and problems as needed.
• Perform adjustments across all dollar levels using claims processing expertise.
• Apply medical necessity guidelines and verify eligibility and coverage.
• Perform claim re-work calculations and address over/underpayments.
• Process complex provider refunds and returned checks.
• Review contracts to confirm overpayments and allocate refunds.
• Handle pre-approvals/pre-authorizations, reconsiderations, or appeals inquiries.
• Ensure compliance and accurate payments per company procedures.
• Review related correspondences and support junior staff as needed.

Conocimientos

Medical claim processing

Production environment experience

Multi-tasking

Communication skills

Educación

High School Diploma or GED

Associate degree (preferred)

Descripción del empleo

CVS Health in Massachusetts is seeking an experienced Medical Claims Processor to review and adjudicate self-funded, fully insured, and RX claims. You will handle complex cases, verify eligibility, and apply medical necessity guidelines to determine coverage.

The role involves processing refunds, handling inquiries, and ensuring compliance while working in a production environment. Benefits include health, dental, and vision coverage, PTO, and wellness programs.