Senior Claim Benefit Specialist

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🕒 July 17

⚜️ Louisiana, Montana, +2 more states – Remote

⚜️ Louisiana – Remote 🦬 Montana – Remote 🌲 North Carolina – Remote 🎸 Mississippi – Remote

💵 $18 - $42 / hour

⏰ Full Time

🟠 Senior

💻 IT Support

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. • Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. • Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience. • 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.

🎯 Requirements

• Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator. • Proven success working in a high‑volume, production‑driven environment. • Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail. • Self-Funding experience (Preferred) • DG system knowledge (Preferred) • High School Diploma required • Preferred Associates degree or equivalent work experience.

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs