Senior Claim Benefit Specialist

CVS Health

Senior Claim Benefit Specialist managing complex medical claims for CVS Health. Providing coaching and support in customer service operations while ensuring compliance with regulations.

Posted 6/21/2026full-timeRemote • Louisiana, Mississippi, Montana, North Carolina • 🇺🇸 United StatesSenior💰 $19 - $42 per hourWebsite

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs and other resources

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical claim processingclaims adjudicationcost-containment measuresclaim rework calculationsmedical necessity guidelinescoverage determinationeligibility verificationdiscrepancy identificationregulatory compliancehigh-volume production

Soft Skills

coachingguidancecustomer serviceissue resolutionattention to detailaccuracyefficiencymulti-taskingmentoringteam performance enhancement

Certifications

High School DiplomaAssociates degree