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Senior Claims Benefit Specialist at CVS Health - ApplyBlast

Senior Claims Benefit Specialist

CVS Health

4 months ago

3.2 on Glassdoor

Minnesota

Onsite

Full Time

Junior

0 applicants

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About this role

A Medical Claims Specialist at CVS Health reviews and adjusts self-funded, fully insured, and reinsurance claims while adjudicating complex, sensitive, or specialized cases according to processing guidelines. The role involves processing provider refunds, handling returned checks, applying medical necessity guidelines, and managing eligibility verifications to ensure compliance and accurate payments. Professionals in this position also handle customer service inquiries regarding pre-approvals and appeals while utilizing technical expertise to resolve claim irregularities.

Responsibilities

Review and adjust complex self-funded and fully insured health claims
Adjudicate specialized cases in accordance with established guidelines
Process provider refunds and manage returned checks accurately
Apply medical necessity guidelines to determine coverage eligibility
Handle customer service inquiries regarding pre-approvals and appeals

Skills

Qualifications

Associate DegreeHigh School Diploma or GED

About CVS Health

cvshealth.com

Headquarters

Woonsocket, Rhode Island, United States

Company Size

10001+ employees

Founded

1963

View Profile

CVS Health is America's leading health solutions company, providing integrated services across retail pharmacy (CVS Pharmacy), pharmacy benefits management (CVS Caremark), and health insurance (Aetna). The company offers pharmacy services, health plans, clinical care (including MinuteClinic), and health-and-wellness programs for consumers, employers, and government payers. By combining a large national retail footprint with claims processing, care management, and clinical services, CVS Health aims to coordinate care, lower costs, and improve health outcomes. Businesses and consumers use its solutions for medication management, plan administration, and in-person and virtual care.