Senior Claims Benefit Specialist

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

📋 Description

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

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

• Process refunds to providers and handle returned checks.

• Address customer service inquiries and resolve issues.

• Execute adjustments at all dollar amounts on customer service platforms.

• Apply medical necessity criteria and assess coverage.

• Conduct eligibility verification and identify discrepancies.

• Implement cost containment strategies during claim adjudication.

• Perform calculations for claim re-work.

• Address claim overpayments, underpayments, and other irregularities.

• Analyze and interpret medical contract language and provider agreements.

• Manage telephone and written inquiries related to pre-approvals, pre-authorizations, reconsiderations, and appeals.

• Ensure compliance with requirements and that payments adhere to company practices and policies.

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

• Provide job shadowing and guidance to less experienced staff members.

• Utilize resource materials effectively to fulfill job responsibilities.

⛳️ Requirements

• A minimum of 2 years of experience in medical claim processing.

• Proven experience in a production environment.

• Capability to manage multiple assignments competently, accurately, and efficiently.

• 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

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

• Comprehensive medical coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off benefits.

• Retirement savings options available.

• Wellness programs to support employee health.

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