Senior Medical Claims & Benefits Specialist - Remote

CVS Health; California; Hybrid; USD 25,000 - 58,000; Full time

Job summary

CVS Health is hiring for a full-time claims adjudicator to review and resolve complex medical claims. You will act as a subject matter expert, coach teammates, and support customer service by addressing inquiries and resolving issues to ensure a positive member experience.

Responsibilities include applying medical necessity guidelines, verifying eligibility, and identifying discrepancies while controlling costs.

Qualifications

• Minimum 18 months of medical claim processing experience.
• Experience in high-volume, production-driven environment.
• Ability to manage multiple assignments with accuracy and efficiency.

Responsibilities

• Review and adjudicate complex medical claims per guidelines.
• Provide coaching and guidance on escalated issues.
• Support customer service by addressing inquiries and resolving issues.
• Apply medical necessity guidelines and verify eligibility.
• Identify discrepancies and implement cost-containment measures.
• Ensure payments align with policies and procedures.
• Conduct outbound calls to obtain information for claims.

Skills

Medical claims processing

High-volume environment

multitasking and accuracy

Education

High School Diploma

Associates degree or equivalent

Tools

DG system knowledge

Self-Funding experience

Job description

CVS Health is hiring for a full-time claims adjudicator to review and resolve complex medical claims. You will act as a subject matter expert, coach teammates, and support customer service by addressing inquiries and resolving issues to ensure a positive member experience.

Responsibilities include applying medical necessity guidelines, verifying eligibility, and identifying discrepancies while controlling costs.