Senior Claim Benefit Specialist

CVS Health

. Review and adjudicate complex, sensitive, and specialized medical claims according to established plan processing guidelines .

Posted 9/24/2026full-timeRemote • United StatesSenior💰 $19 - $42 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claim processing, ensuring compliance with regulatory standards while effectively managing high-volume workloads. Capable of training and mentoring team members, providing guidance on complex claims, and implementing cost-containment measures.

Highest-signal resume keywords

Medical Claim Processing ExperienceRegulatory ComplianceCost-Containment MeasuresHigh-Volume Production EnvironmentTraining and Mentoring

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationMedical Necessity GuidelinesCoverage DeterminationEligibility VerificationClaim Rework Calculations

Soft Skills

Attention to DetailProblem SolvingCoaching

Tools & Technologies

DG System Knowledge

Industry Keywords

Health InsuranceThird-Party AdministratorSelf-Funding

About the role

Key responsibilities & impact

Review and adjudicate complex, sensitive, and specialized medical claims according to established plan processing guidelines
Provide subject matter expertise, coaching, and guidance on escalated or technically challenging issues
Support customer service operations by addressing inquiries and resolving issues
Review pre-specified claims and claims exceeding specialist adjudication authority or processing expertise
Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and implement cost-containment measures
Ensure regulatory compliance and verify payments align with company policies and procedures
Identify and report potential overpayments, underpayments, and other claim irregularities
Perform claim rework calculations
Train and mentor team members as needed
Conduct outbound calls to obtain required information for claims or reconsideration requests

Requirements

What you’ll need

Minimum of 18 months of medical claim processing experience with a health insurance payor or third-party administrator
Proven success working in a high-volume, production-driven environment
Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail
High School Diploma required
Self-Funding experience preferred
DG system knowledge preferred
Preferred Associates degree or equivalent work experience

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being