Senior Claim Benefit Adjuster

This is a fully remote position, open to applicants in Alabama, +44 more locations.

📋 Description

• Review and modify claims for self-funded (SF), fully insured (FI), reinsurance, and/or prescription (RX) cases.

• Adjudicate complex, sensitive, and specialized claims in accordance with established processing guidelines.

• Process refunds from providers and manage returned checks.

• Address customer service inquiries and resolve issues.

• Execute adjustments on customer service platforms at all dollar levels utilizing technical expertise and claims processing knowledge.

• Implement medical necessity guidelines to assess coverage.

• Conduct eligibility verification and pinpoint discrepancies.

• Enforce cost containment strategies during the adjudication of claims.

• Execute calculations for claim rework.

• Address claim overpayments, underpayments, and other irregularities.

• Process intricate non-routine provider refunds and manage returned checks.

• Analyze and interpret medical contract language and provider agreements to confirm claim overpayments and allocate refund checks accordingly.

• Respond to telephone and written inquiries related to pre-approvals, reconsiderations, or appeals.

• Ensure compliance with regulatory requirements while adhering to company practices and procedures for payments.

• Review and manage correspondence that may lead to claim adjustments.

• Provide job shadowing to less-experienced colleagues as required.

• Use resource materials effectively to fulfill job responsibilities.

⛳️ Requirements

• Minimum of 2 years' experience in medical claim processing.

• At least 2 years of experience in a production environment.

• Proven ability to manage multiple assignments with competence, accuracy, and efficiency.

• Strong communication, organizational, and interpersonal skills.

• High School Diploma or GED is required.

• Experience with DG system claims processing is preferred.

• An associate degree is preferred.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources that promote physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs in addition to base pay.