Senior Medical Claims Specialist - Remote

CVS Health; Connecticut; 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

Wellness programs

Job summary

CVS Health in the United States is seeking a knowledgeable claims adjudicator to review and adjudicate complex medical claims in line with processing guidelines. You will coach colleagues and guide escalated issues while supporting customer service with inquiries to ensure a positive member experience.

The role involves applying medical necessity guidelines, verifying coverage, and ensuring accuracy in payments, with a focus on cost containment and compliance across processes.

Qualifications

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

Responsibilities

• Review pre-specified claims and those beyond adjudication authority.
• Apply medical necessity guidelines, verify coverage and eligibility, and implement cost-containment measures.
• Ensure payments align with company policies and procedures.
• Identify and report potential overpayments, underpayments, and other claim irregularities.
• Perform claim rework calculations as needed.
• Train and mentor as needed to enhance team performance and technical proficiency.
• Conduct outbound calls to obtain required information for claims or reconsideration requests.

Skills

Medical claim processing

High‑volume environment

Attention to detail

Education

High School Diploma

Associates degree or equivalent work experience

Tools

DG system knowledge

Job description

CVS Health in the United States is seeking a knowledgeable claims adjudicator to review and adjudicate complex medical claims in line with processing guidelines. You will coach colleagues and guide escalated issues while supporting customer service with inquiries to ensure a positive member experience.

The role involves applying medical necessity guidelines, verifying coverage, and ensuring accuracy in payments, with a focus on cost containment and compliance across processes.