Medical Claims Adjuster

CVS Health

1d • $19 - $42

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. The Medical Claims Adjuster will review and adjust claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Process provider refunds and returned checks. May handle customer service inquiries and problems. Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Performs claim re-work calculations. Follow through completion of claim overpayments, underpayments, and any other irregularities. Process complex non-routine Provider Refunds and Returned Checks. Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks. Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals. Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures. Review and handle relevant correspondences assigned to the team that may result in adjustment to claims. May provide job shadowing to lesser experience staff. Utilize all resource materials to manage job responsibilities.

Requirements

• 2+ years medical claim processing experience
• Experience in a production environment
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently
• Effective communications, organizational, and interpersonal skills
• High school Diploma required

Nice To Haves

• 1-2 years of experience in a production environment DG system claims processing experience
• Associate Degree or equivalent experience preferred

Responsibilities

• Review and adjust claims
• Adjudicate complex, sensitive, and/or specialized claims in accordance with claim processing guidelines
• Process provider refunds and returned checks
• Handle customer service inquiries and problems
• Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise
• Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
• Perform claim re-work calculations
• Follow through completion of claim overpayments, underpayments, and any other irregularities
• Process complex non-routine Provider Refunds and Returned Checks
• Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals
• Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures
• Review and handle relevant correspondences assigned to the team that may result in adjustment to claims
• Provide job shadowing to lesser experience staff
• Utilize all resource materials to manage job responsibilities

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED