[Hiring] Senior Claims Benefit Specialist @CVS Health

Role 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 levels on customer service platforms using technical and claims processing expertise.
• 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.

Qualifications

• 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.

Requirements

• DG system claims processing experience (preferred).
• Associate degree preferred.
• High School Diploma or GED.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.