Senior Claims Benefit Specialist - Remote

Lensa is a career site that helps job seekers find great jobs in the US. We are not a staffing firm or agency. Lensa does not hire directly for these jobs, but promotes jobs on LinkedIn on behalf of its direct clients, recruitment ad agencies, and marketing partners. 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. 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. Identifies and reports possible claim overpayments, underpayments and any other irregularities. Performs claim rework calculations. Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration. 2+ years medical claim processing experience. ~High School Diploma required Preferred Associates degree or equivalent work experience. Full time This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. 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. We anticipate the application window for this opening will close on: 07/21/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. Employment type Full-time Sign in to set job alerts for “Senior Claims Specialist” roles. We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI. #