Senior Medical Claims & Benefits Specialist

CVS Health; Williamstown (NJ); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Bonus eligibility

Competitive benefits

Job summary

CVS Health is seeking a full-time Claims Processor in New Jersey to review and adjudicate self-funded, fully insured, and RX claims. The role involves processing provider refunds, handling customer inquiries, and applying medical necessity guidelines to determine coverage and eligibility.

Qualified candidates typically have 2+ years of medical claim processing experience in a production environment, with strong communication and organizational skills to manage multiple tasks efficiently.

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 (self-funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.
• Process provider refunds and returned checks.
• May handle customer service inquiries and problems.
• Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
• Performs claim re-work calculations.
• Follow through completion of claim overpayments, underpayments, and any other irregularities.

Skills

Medical claim processing

Multitasking

Communication skills

Organizational skills

Education

High School Diploma or GED

Job description

CVS Health is seeking a full-time Claims Processor in New Jersey to review and adjudicate self-funded, fully insured, and RX claims. The role involves processing provider refunds, handling customer inquiries, and applying medical necessity guidelines to determine coverage and eligibility.

Qualified candidates typically have 2+ years of medical claim processing experience in a production environment, with strong communication and organizational skills to manage multiple tasks efficiently.