Senior Medical Claims Specialist — Remote

CVS Health; Atlanta (GA); On-site; USD 26,000 - 58,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Coverage

Paid Time Off

Retirement Savings

Wellness programs

Job summary

CVS Health in Atlanta, GA is seeking a Claims Adjudicator to review and adjudicate complex medical claims in line with plan guidelines. You will serve as a subject matter expert, coach teammates, and support customer service by resolving inquiries to ensure a positive member experience.

Qualifications include at least 18 months of medical claim processing experience in a health plan setting, comfort working in a high-volume environment, and strong accuracy and attention to detail.

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

• Reviews pre-specified claims and those beyond adjudication authority.
• Applies medical necessity guidelines and determines coverage.
• Verifies eligibility and identifies discrepancies to support accurate adjudication.
• Ensures payments comply with company policies and procedures.
• Identifies and reports potential overpayments/underpayments.
• Performs claim rework calculations as needed.
• Trains and mentors teammates to enhance performance.
• Conducts outbound calls to obtain required information.

Education

High School Diploma

Associates degree or equivalent

Job description

CVS Health in Atlanta, GA is seeking a Claims Adjudicator to review and adjudicate complex medical claims in line with plan guidelines. You will serve as a subject matter expert, coach teammates, and support customer service by resolving inquiries to ensure a positive member experience.

Qualifications include at least 18 months of medical claim processing experience in a health plan setting, comfort working in a high-volume environment, and strong accuracy and attention to detail.