Senior Claim Benefit Specialist, Remote at CVS Health

Overview

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 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.

Additional Responsibilities - 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. Required Qualifications - 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. Preferred Qualifications - Self-Funding experience - DG system knowledge Education - High School Diploma required - Preferred Associates degree or equivalent work experience.

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. This full‑time position is eligible for a comprehensive

Benefits

• package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The

Benefits

• for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available

Benefits

• are provided during the application process and on

Benefits

• Moments .
• This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis.
• Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.