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Senior Claim Benefit Specialist, Operations – Encounters
CVS Health. Research, review, and adjudicate complex, sensitive, and specialized encounters according to state-specific processing guidelines .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical claims processing, particularly in Medicaid and Medicare, with strong analytical skills for resolving encounter errors and ensuring claim payment accuracy. Proficient in utilizing MS Office Suite and familiar with claims processing systems like QNXT and Edifecs.
Highest-signal resume keywords
Medical Claims ProcessingAnalytical SkillsMS Office Suite ProficiencyQnxt Claims ProcessingEncounter Resolution
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AdjudicationClaims ProcessingResearch SkillsProblem-SolvingProduction Environment Experience
Soft Skills
Team CollaborationIndependent WorkTime Management
Tools & Technologies
MS ExcelMS WordMS OneNoteEdifecs SystemFacets Claims Processing
Industry Keywords
MedicaidMedicareEncounter ProcessingClaims Payment AccuracyStandardized Procedures
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 development of 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