Senior Claims Benefit Specialist

CVS Health

About The Position

The Senior Claims Benefit Specialist will review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims. They will adjudicate complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. This person will also process provider refunds and returned checks. They also may handle customer service inquiries and problems. The role involves performing adjustments across all dollar amount levels on customer service platforms, specifically by using technical and claims processing expertise. It requires applying medical necessity guidelines, determining coverage, completing eligibility verification, identifying discrepancies, and applying all cost containment measures to assist in the claim adjudication process. The specialist will perform claim re-work calculations and follow through with completion of claim overpayments, underpayments, and any other irregularities. They will 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, in order to allocate refund checks. The position also entails handling telephonic and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals, ensuring all compliance requirements are satisfied and that all payments are made following company practices and procedures. They will review and handle relevant correspondences assigned to the team that may result in adjustment to claims, and may provide job shadowing to less experienced staff members, utilizing all resource materials to manage job responsibilities.

Requirements

2+ years of experience with medical claim processing.
2+ years of experience in a production environment.

Nice To Haves

Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
Effective communication, organizational, and interpersonal skills.
Previous experience with DG system claims processing.

Responsibilities

Perform adjustments across all dollar amount levels on customer service platforms, specifically 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 with 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, in order to allocate refund checks.
Handle telephonic 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.
May provide job shadowing to less experienced staff members.
Utilize all resource materials to manage job responsibilities.