Senior Remote Claims Benefit Specialist

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

Avantages offerts par ce poste

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Résumé du poste

CVS Health in Arizona is seeking a Claims Adjudicator to review and adjudicate complex medical claims in line with processing guidelines. You will act as a subject matter expert, coaching others and guiding on escalated issues to ensure a positive member experience.

The role involves applying guidelines, verifying coverage, and supporting accurate adjudication. A 40-hour work week and full-time status accompany a comprehensive benefits package.

Qualifications

• Minimum 18 months of medical claim processing experience.
• Experience in a high-volume, production-driven environment.
• Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail.
• DG system knowledge is preferred.

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

Medical claim processing

High-volume environment

Attention to detail

Time management

Formation

High School Diploma

Associates degree

Outils

DG system knowledge

Description du poste

CVS Health in Arizona is seeking a Claims Adjudicator to review and adjudicate complex medical claims in line with processing guidelines. You will act as a subject matter expert, coaching others and guiding on escalated issues to ensure a positive member experience.

The role involves applying guidelines, verifying coverage, and supporting accurate adjudication. A 40-hour work week and full-time status accompany a comprehensive benefits package.