[Hiring] Senior Claims Benefit Specialist @CVS Health

Role Description

This position involves reviewing and adjusting SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims, and adjudicating complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.

• Process provider refunds and returned checks
• 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 on 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 experienced 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

Education

• High School Diploma or GED

Anticipated Weekly Hours

• 40

Time Type

• Full time

Pay Range

The typical pay range for this role is: $18.50 - $42.35. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography, and other relevant factors. This position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range listed above.

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation, and weight management programs, confidential counseling, and financial coaching
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access, and many other benefits depending on eligibility

Application Information

We anticipate the application window for this opening will close on: 02/25/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.