Senior Claims Benefit Specialist

This is a fully remote position, open to applicants in New York.

📋 Description

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

• Assess intricate, sensitive, and/or specialized claims in accordance with processing guidelines.

• Process refunds for providers and manage returned checks.

• Execute claim adjustments at all monetary levels utilizing technical expertise and claims processing knowledge.

• Implement medical necessity guidelines to ascertain coverage.

• Conduct eligibility verifications and identify any discrepancies.

• Employ cost containment strategies during the claim adjudication process.

• Perform recalculations on claims as necessary.

• Address claim overpayments, underpayments, and other inconsistencies.

• Analyze and interpret medical contract terms and provider agreements to validate overpayments and facilitate refund check allocation.

• Manage phone and written queries related to pre-approvals/pre-authorizations, reconsiderations, and appeals.

• Ensure adherence to compliance requirements and company payment policies.

• Review pertinent correspondence that may necessitate claim adjustments.

• Provide mentorship to less experienced staff when required.

• Utilize resource materials effectively to fulfill job responsibilities.

⛳️ Requirements

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

• Experience in a high-volume production setting.

• Proven capability to manage multiple tasks competently, accurately, and efficiently.

• Strong communication, organizational, and interpersonal skills.

• High School Diploma or GED required.

• Experience with DG system claims processing is preferred.

• An Associate degree is preferred.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being, subject to eligibility.