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CVS Health · 1 day ago

Senior Claim Benefit Specialist

St Paul, MN

Full-time

Onsite

Mid, Senior Level

$18.50/hr - $42.35/hr

1+ years exp

CVS Health is the nation’s leading health solutions company, dedicated to transforming health care. The Senior Claim Benefit Specialist reviews and adjudicates complex claims, acting as a subject matter expert while providing training and handling customer service inquiries.

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Responsibilities

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

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 assignment daily to junior staff

Trains and mentors claim benefit specialists

Makes outbound calls to obtain required information for claim or reconsideration