Senior Claims Benefit Specialist

CVS Health Careers

. Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims .

Posted 11/3/2026full-timeRemote • New York • United StatesSenior💰 $19 - $42 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claim processing, including adjudication of complex claims, eligibility verification, and compliance with payment procedures. Proficient in applying medical necessity guidelines and managing provider contracts to ensure accurate claim adjustments and cost containment.

Highest-signal resume keywords

Medical Claim Processing ExperienceClaims AdjudicationEligibility VerificationCost Containment MeasuresEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims Processing ExpertiseClaim AdjustmentsOverpayment and Underpayment ReviewReinsurance ClaimsSelf-Funded ClaimsFully Insured ClaimsProvider Refund ProcessingClaim Re-Work CalculationsMedical Necessity GuidelinesCompliance Requirements

Soft Skills

Organizational SkillsInterpersonal SkillsAbility to Handle Multiple AssignmentsEffective Communication

Tools & Technologies

DG System Claims Processing

Certifications & Qualifications

High School DiplomaGEDAssociate Degree

Industry Keywords

Claims Processing GuidelinesProvider ContractsCost ContainmentPre-ApprovalsReconsiderationsAppeals

About the role

Key responsibilities & impact

Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims
Adjudicate complex, sensitive, and/or specialized claims according to claim processing guidelines
Process provider refunds and returned checks
Perform claim adjustments across all dollar amount levels using technical and claims processing expertise
Apply medical necessity guidelines and determine coverage
Complete eligibility verification and identify discrepancies
Apply cost containment measures during claim adjudication
Perform claim re-work calculations
Complete claim overpayments, underpayments, and other irregularities
Review and interpret medical contract language and provider contracts to confirm overpayments and allocate refund checks
Handle telephone and written inquiries regarding pre-approvals/pre-authorizations, reconsiderations, and appeals
Ensure compliance requirements and company payment procedures are satisfied
Review relevant correspondence that may require claim adjustments
Provide job shadowing to less experienced staff when needed
Utilize resource materials to manage job responsibilities

Requirements

What you’ll need

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 or GED
DG system claims processing experience preferred
Associate degree preferred

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program in addition to base pay
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being, based on eligibility