Senior Medical Claims & Benefits Specialist

CVS Health; Salem (OR); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Comprehensive benefits

Bonus eligibility

Job summary

CVS Health is seeking a Claims Processor who will review and adjudicate complex self-funded, fully insured, and RX claims, ensuring compliance with processing guidelines. The role also processes refunds, handles customer inquiries, and supports pre-authorizations and appeals as needed.

The ideal candidate has at least 2 years of medical claim processing experience, works well in a production environment, and demonstrates strong communication, organization, and interpersonal skills.

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.
• DG system claims processing experience.
• Associate degree preferred.

Responsibilities

• Review and adjudicate complex claims across self-funded, fully insured, and RX programs.
• Process provider refunds and returned checks.
• Handle customer service inquiries related to pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and that payments follow company procedures.
• Review correspondences and adjust claims as needed.
• May provide job shadowing to lesser experienced staff.
• Utilize resource materials to manage responsibilities.

Skills

Effective communications

Organizational skills

Interpersonal skills

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health is seeking a Claims Processor who will review and adjudicate complex self-funded, fully insured, and RX claims, ensuring compliance with processing guidelines. The role also processes refunds, handles customer inquiries, and supports pre-authorizations and appeals as needed.

The ideal candidate has at least 2 years of medical claim processing experience, works well in a production environment, and demonstrates strong communication, organization, and interpersonal skills.