Senior Claim Benefit Specialist – Work From Home

Senior Claim Benefit Specialist – Work From Home

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Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

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 Duties

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. measures to assist in the claim adjudication process.
  • 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 assignments daily to junior staff.
  • Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration.

 

 

Required Qualifications

  • 2+ years claim processing experience.
  • Experience in a production environment.
  • Claim processing experience.
  • Demonstrated ability to handle multiple assignments

competently, accurately and efficiently.

Preferred Qualification

  • Medical Claim processing experience
  • Familiar with diagnosing codes

Senior Claim Benefit Specialist – Work From Home

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