Senior Claim Benefit Specialist

Senior Claim Benefit Specialist

At CVS Health, 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 reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

The Senior Claim Benefit Specialist reviews and adjudicates complex, sensitive, and / or specialized claims in accordance with plan processing guidelines. This person acts as a subject matter expert by providing training, coaching, and / or responding to complex issues. They may also 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 all cost containment measures to assist in the claim adjudication process.

Handles phone and written inquiries related to requests for pre-approval / pre-authorization, reconsiderations, or appeals.

Ensures all compliance requirements are satisfied, and all 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 :

At least 18 months of experience in medical claim processing.

At least 18 months of experience in a production environment.

Preferred Qualifications :

Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Previous experience with self-funding.

Demonstrated knowledge of and proficiency with DG system.

Associate's degree or higher.

Education :

High school diploma or GED.

Anticipated Weekly Hours : 40

Time Type : Full time

Pay Range : The typical pay range for this role is : $18.50 - $42.35. 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 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 all 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 access and many other benefits depending on eligibility.