Senior Claims Benefit Specialist
CVS Health
full-time
Posted on:
Location Type: Remote
Location: Idaho • Minnesota • United States
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Salary
💰 $19 - $42 per hour
Job Level
About the role
- Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims
- Adjudicate 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
- Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures
- Perform claim re-work calculations
- Follow through completion of claim overpayments, underpayments, and any other irregularities
- Review and interpret medical contract language using provider contracts
- 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
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
- 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
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
- Many other benefits depending on eligibility
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical claim processingclaim adjudicationeligibility verificationclaim re-work calculationscost containment measuresprovider refunds processingpre-approvalspre-authorizationsdiscrepancy identificationcompliance requirements
Soft Skills
effective communicationorganizational skillsinterpersonal skillsability to handle multiple assignmentsaccuracyefficiency
Certifications
Associate degree