Senior Claims Benefit Specialist

Job Description:

• Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims
• Adjudicate complex, sensitive, and/or specialized claims according to claim processing guidelines
• Process provider refunds and returned checks
• Handle customer service inquiries and problems
• Perform adjustments across all dollar amount levels on customer service platforms
• Apply medical necessity guidelines and determine coverage
• Complete eligibility verification and identify discrepancies
• Apply cost containment measures during claim adjudication
• Perform claim re-work calculations
• Complete claim overpayments, underpayments, and other irregularities
• Review and interpret medical contract language and provider contracts
• Handle telephone and written inquiries regarding pre-approvals, pre-authorizations, reconsiderations, and appeals
• Ensure compliance requirements are satisfied and payments follow company practices and procedures
• Review and handle correspondence that may result in claim adjustments
• Provide job shadowing to less experienced staff
• Utilize resource materials to manage job responsibilities

Requirements:

• 2+ years medical claim processing experience
• Experience in a production environment
• Ability to handle multiple assignments competently, accurately, and efficiently
• Effective communications, organizational, and interpersonal skills
• High School Diploma or GED
• DG system claims processing experience preferred
• Associate degree preferred

Benefits:

• CVS Health bonus, commission or short-term incentive program in addition to base pay
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being