Senior Claims Benefit Specialist

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🕒 2 days ago

🥔 Idaho, Minnesota, +1 more states – Remote

🥔 Idaho – Remote ❄️ Minnesota – Remote 🤠 Texas – Remote

💵 $18 - $42 / hour

⏰ Full Time

🟠 Senior

💻 IT Support

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

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

• review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims • adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines • process provider refunds and returned checks • may handle customer service inquiries and problems • perform adjustments across all dollar amount level on customer service platforms • apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process • perform claim re-work calculations • follow through completion of claim overpayments, underpayments, and any other irregularities • process complex non-routine Provider Refunds and Returned Checks • review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks • handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals • ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures • review and handle relevant correspondences assigned to the team that may result in adjustment to claims • may provide job shadowing to lesser experience staff • utilize all resource materials to manage job responsibilities

🎯 Requirements

• 2+ years medical claim processing experience • experience in a production environment • demonstrated ability to handle multiple assignments competently, accurately, and efficiently • effective communications, organizational, and interpersonal skills • DG system claims processing experience preferred • associate degree preferred

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • other resources, based on eligibility