Senior Claims Benefit Specialist

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

The Senior Claims Benefit Specialist will review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims. They will adjudicate complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.  This person will also process provider refunds and returned checks. They also may handle customer service inquiries and problems.

In this role, you will:

• Perform adjustments across all dollar amount levels on customer service platforms, specifically by 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 with 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, in order to allocate refund checks.
• Handle telephonic 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 less experienced staff members.
• Utilize all resource materials to manage job responsibilities.
   

Required Qualifications

• 2+ years of experience with medical claim processing.
• 2+ years of experience in a production environment.

Preferred Qualifications

• Previous experience working with overpayments.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communication, organizational, and interpersonal skills.
• Previous experience with DG system claims processing.

Education

• Associate’s degree or equivalent experience (high school diploma or GED + 2 years of relevant experience).

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.