Senior Claims Benefit Specialist

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. May handle customer service inquiries and problems. Perform adjustments across all dollar amount levels on customer service platforms 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 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 to allocate refund checks.

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 that may result in adjustment to claims. May provide job shadowing to lesser experienced staff. Utilize all resource materials to manage job responsibilities.

Responsibilities

• 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, and identify discrepancies.
• Perform claim re-work calculations and follow through on claim overpayments, underpayments, and irregularities.
• Process complex non-routine Provider Refunds and Returned Checks.
• Review and interpret medical contract language to confirm claim overpayments and allocate refund checks.
• Handle telephone and written inquiries for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance with company practices and procedures for all payments.
• Review and handle correspondences that may result in claim adjustments.
• Provide job shadowing to lesser experienced staff.

Requirements

• 2+ years of medical claim processing experience.
• Experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communication, organizational, and interpersonal skills.

Preferred Qualifications

• DG system claims processing experience.
• Associate degree preferred.

Qualifications

High School Diploma or GED.

Pay

The typical pay range for this role is $18.50 - $42.35 per hour. This pay range represents the base hourly rate 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.

Benefits

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. Benefits include:

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

Schedule

• Anticipated weekly hours: 40
• Time type: Full time