Senior Medical Claims Specialist: Adjudication & Refunds

CVS Health; Pennsylvania; On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a full-time medical claims processor in Pennsylvania to review and adjudicate complex claims across self-funded and fully insured plans, process refunds, and handle inquiries. The role emphasizes adherence to guidelines, cost containment, and accurate payments.

Qualified candidates will have 2+ years of claim processing experience in a production setting, strong communication skills, and the ability to juggle 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.
• Process complex non-routine Provider Refunds and Returned Checks.
• Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks.
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures.
• Review and handle relevant correspondences assigned to the team that may result in adjustment to claims.
• May provide job shadowing to lesser experience staff.
• Utilize all resource materials to manage job responsibilities

Skills

Medical claim processing

Production environment

Multitasking

Communication

Education

High School Diploma or GED

Associate degree preferred

Job description

CVS Health is seeking a full-time medical claims processor in Pennsylvania to review and adjudicate complex claims across self-funded and fully insured plans, process refunds, and handle inquiries. The role emphasizes adherence to guidelines, cost containment, and accurate payments.

Qualified candidates will have 2+ years of claim processing experience in a production setting, strong communication skills, and the ability to juggle multiple tasks efficiently.