CVS Health · 8 hours ago
Senior Claim Benefit Specialist - Remote
United States
Full-time
Remote
Mid, Senior Level
$18.50/hr - $42.35/hr
1+ years expCVS Health is dedicated to building a more connected and compassionate health experience. The Senior Claim Benefit Specialist is responsible for reviewing and adjudicating complex medical claims, providing guidance on escalated issues, and ensuring compliance with regulatory requirements to enhance member experience.
Health CareMedicalPharmaceuticalRetailSales
Responsibilities
Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines
Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues
Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience
Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise
Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication
Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures
Identifies and reports potential overpayments, underpayments, and other claim irregularities
Performs claim rework calculations as needed
Trains and mentors as needed to enhance team performance and technical proficiency
Conducts outbound calls to obtain required information for claims or reconsideration requests
Qualification
Required
Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator
Proven success working in a high‑volume, production‑driven environment
Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail
High School Diploma required
Preferred
Self-Funding experience
DG system knowledge
Preferred Associates degree or equivalent work experience
Benefits
Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility
Company
CVS Health
CVS Health is a health solutions company that provides an integrated healthcare services to its members.
10001+ employees
Funding
Current Stage
Public CompanyTotal Funding
$4BKey Investors
Michigan Economic Development CorporationStarboard Value
2025-08-15Post Ipo Debt· $4B
2025-07-17Grant· $1.5M
2019-11-25Post Ipo Equity
Leadership Team
David Joyner
President and Chief Executive Officer, CVS Health
Chandra McMahon
SVP & CISO
Recent News
2026-01-25
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