Senior Claims Benefit Specialist - Remote

At reputed company, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. Position Summary Reviews and adjudicates reputed company, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to reputed company issues. May handle customer service inquiries and problems. Additional Responsibilities

• Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies reputed company cost containment. measures to assist in the claim adjudication process.
• Handles phone and written inquiries reputed company to requests for pre-approval/pre-authorization, reconsiderations, or appeals.
• Insures reputed company compliance requirements are satisfied and reputed company payments are made against company practices and procedures.
• Identifies and reports possible claim overpayments, underpayments and any other irregularities.
• Performs claim rework calculations.
• Distributes work assignment daily to junior staff.
• Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration.

Required Qualifications

• 2+ years medical claim processing experience.
• 1-2 years Experience in a production/ metrics based environment
• Demonstrated ability to handle multiple assignments competently, accurately and reputed company.
• Preferred Qualifications
• Self-Funding experience
• DG system knowledge

Education

• High School Diploma required
• Preferred Associates degree or equivalent work experience.

Anticipated Weekly Hours 40 Time Type Full time Pay reputed company The typical pay reputed company for this role is: $18.50 - $38.82 This pay reputed company represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay reputed company 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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for reputed company 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 reputed company and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 07/21/2025 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply tot his job Apply To this Job