Senior Claim Benefit Specialist, Operations

CVS Health

. Research, review, and adjudicate complex, sensitive, and specialized encounters according to state-specific processing guidelines .

Posted 11/9/2026full-timeRemote • United StatesSenior💰 $19 - $35 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claims processing, particularly in Commercial, Medicaid, and Medicare environments, while effectively resolving encounter errors and ensuring claim payment accuracy. Proficient in utilizing analytical skills to support cross-functional collaboration and meet production expectations.

Highest-signal resume keywords

Medical Claims Processing ExperienceAnalytical And Problem-Solving SkillsProficiency In MS Office SuiteQNXT Or Facets Claims Processing ExperienceEncounters Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Claims ProcessingEncounter AdjudicationClaims Processing SystemResearching ClaimsQuality And Production Expectations

Soft Skills

Ability To Work IndependentlyTeam CollaborationBalancing Competing Priorities

Tools & Technologies

MS Office SuiteExcelWordOneNoteEdifecs System Knowledge

Industry Keywords

Commercial ClaimsMedicaid ClaimsMedicare ClaimsState-Specific Processing GuidelinesCross-Functional Partnership

About the role

Key responsibilities & impact

Research, review, and adjudicate complex, sensitive, and specialized encounters according to state-specific processing guidelines
Drive timely resolution of encounter errors using available resources, tools, and research
Adjudicate complex, sensitive, and specialized claims accurately in the claims processing system
Meet quality and production expectations
Identify and escalate issues affecting claim payment accuracy or creating rework
Partner cross-functionally to resolve barriers to encounter acceptance
Contribute to developing desktops and standardized procedures
Balance competing priorities while supporting multiple markets
Participate in working sessions and meetings advancing business objectives and KPIs

Requirements

What you’ll need

Minimum 2 years of medical claims processing experience (Commercial, Medicaid, Medicare)
Experience working in a production environment
Strong analytical and problem-solving skills, especially in researching claims
Proficiency in MS Office Suite applications; Excel, Word, OneNote
Ability to work independently and as a team
High School Diploma
QNXT or Facets claims processing experience (preferred)
Experience in Medicaid or Medicare claims (preferred)
Encounters experience (preferred)
Edifecs system knowledge (preferred)

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, based on eligibility