Senior Medical Claims Specialist — Remote

CVS Health; Pennsylvania; Hybride; USD 25 000 - 58 000; Plein temps

Avantages offerts par ce poste

Health Insurance

Dental Insurance

Vision Insurance

401(k) Plan

Paid Time Off

Résumé du poste

CVS Health is seeking a full‑time Medical Claims Adjudicator to review and adjudicate complex medical claims in line with processing guidelines. The role involves coaching teammates, handling escalated issues, and supporting customer service with inquiries to ensure a positive member experience.

You will apply medical necessity guidelines, verify eligibility, identify discrepancies, and implement cost containment measures while ensuring regulatory compliance and accurate payments.

Qualifications

• Minimum 18 months of medical claim processing experience with a health insurer or third‑party administrator.
• Experience in a high‑volume, production‑driven environment.
• Ability to manage multiple assignments with accuracy and efficiency.

Responsabilités

• Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication.
• Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures.
• Identifies and reports potential overpayments, underpayments, and other claim irregularities.
• Performs claim rework calculations as needed.
• Trains and mentors as needed to enhance team performance and technical proficiency.
• Conducts outbound calls to obtain required information for claims or reconsideration requests.

Connaissances

Attention to detail

High-volume environment

Time management

Formation

High School Diploma

Associate degree or equivalent

Description du poste

CVS Health is seeking a full‑time Medical Claims Adjudicator to review and adjudicate complex medical claims in line with processing guidelines. The role involves coaching teammates, handling escalated issues, and supporting customer service with inquiries to ensure a positive member experience.

You will apply medical necessity guidelines, verify eligibility, identify discrepancies, and implement cost containment measures while ensuring regulatory compliance and accurate payments.