Senior Claim Benefit Specialist

CVS Health

2d•$19 - $42

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. 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 Responsibilities: 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.

Requirements

New York Independent Adjuster License
Experience in a production environment.
Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
High School Diploma required

Nice To Haves

18+ months of medical claim processing experience
Self-Funding experience
DG system knowledge
Preferred Associates degree or equivalent work experience.

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.

Benefits

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an 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.

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