Senior Claim Benefit Specialist

Position Summary

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. 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.

Additional Responsibilities

• 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.
• Handles phone and written inquiries related to requests for pre-approval / pre-authorization, reconsiderations, or appeals.
• Ensures 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.

Required Qualifications

Preferred Qualifications

Education

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is : $18.50 - $42.35

Great Benefits for Great People

We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include :

For more information, visit https : / / jobs.cvshealth.com / us / en / benefits

We anticipate the application window for this opening will close on : 10 / 31 / 2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex / gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.