CVS Health · 4 days ago
Senior Claim Benefit Specialist - Remote
United States
Full-time
Remote
Mid, Senior Level
$18.50/hr - $42.35/hr
1+ years expCVS Health is building a world of health around every individual, aiming to simplify health care for communities. The Senior Claim Benefit Specialist will review and adjudicate complex claims while serving as a subject matter expert, providing training and support to junior staff.
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Responsibilities
Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines
Acts as a subject matter expert by providing training, coaching, or responding to complex issues
May handle customer service inquiries and problems
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
Insures 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
Qualification
Required
18+ months of medical claim processing experience
Experience in a production environment
Demonstrated ability to handle multiple assignments competently, accurately and efficiently
High School Diploma required
Preferred
Self-Funding experience
DG system knowledge
Preferred Associates degree or equivalent work experience
Benefits
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.
Company
CVS Health
CVS Health is a health solutions company that provides an integrated healthcare services to its members.
10001+ employees
Funding
Current Stage
Public CompanyTotal Funding
$4BKey Investors
Michigan Economic Development CorporationStarboard Value
2025-08-15Post Ipo Debt· $4B
2025-07-17Grant· $1.5M
2019-11-25Post Ipo Equity
Leadership Team
David Joyner
President and Chief Executive Officer, CVS Health
Chandra McMahon
SVP & CISO
Recent News
2026-01-25
Company data provided by crunchbase