Senior Medical Claims Specialist - Benefit Adjudication

Careerwebsite; Idaho; Hybrid; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking a Claims Processor to review and adjudicate complex medical claims in line with plan guidelines, acting as a subject matter expert and providing coaching on escalated issues.

You will support customer service by addressing inquiries, verify eligibility, apply medical necessity guidelines, and ensure payments comply with policies and regulatory requirements while mentoring teammates.

Qualifications

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

Responsibilities

• Review claims within processing guidelines and adjudicate complex cases.
• Apply medical necessity guidelines and verify eligibility.
• Identify discrepancies and implement cost containment.
• Ensure payments align with policies and regulatory requirements.
• Identify and report overpayments, underpayments and irregularities.
• Train and mentor team to enhance performance.
• Conduct outbound calls to obtain required information for reconsiderations.

Skills

Medical claim processing

Attention to detail

High-volume environment

Education

High School Diploma

Associate degree or equivalent

Tools

DG system knowledge

Job description

CVS Health is seeking a Claims Processor to review and adjudicate complex medical claims in line with plan guidelines, acting as a subject matter expert and providing coaching on escalated issues.

You will support customer service by addressing inquiries, verify eligibility, apply medical necessity guidelines, and ensure payments comply with policies and regulatory requirements while mentoring teammates.