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Senior Claims Benefit Specialist
CVS Health. Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical claim processing, including adjudication of complex claims, eligibility verification, and compliance with processing guidelines. Proficient in handling customer service inquiries and applying medical necessity guidelines to ensure accurate claim resolutions.
Highest-signal resume keywords
Medical Claim Processing ExperienceAdjudication Of Complex ClaimsEligibility VerificationEffective Communication SkillsDG System Claims Processing Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claim Processing GuidelinesCost Containment MeasuresClaim Re-Work CalculationsMedical Contract Language InterpretationClaim Overpayments And UnderpaymentsProvider Refund ProcessingPre-Approvals And Pre-AuthorizationsClaims AdjustmentsCustomer Service PlatformsDiscrepancy Identification
Soft Skills
Organizational SkillsInterpersonal SkillsAbility To Handle Multiple Assignments
Certifications & Qualifications
High School DiplomaGEDAssociate Degree Preferred
Industry Keywords
Self-Funded ClaimsFully Insured ClaimsReinsurance ClaimsRX ClaimsCompliance Requirements
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
- Handle customer service inquiries and problems
- Perform adjustments across all dollar amount levels on customer service platforms
- 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
- Handle telephone and written inquiries regarding pre-approvals, pre-authorizations, reconsiderations, and appeals
- Ensure compliance requirements are satisfied and payments follow company practices and procedures
- Review and handle correspondence that may result in claim adjustments
- Provide job shadowing to less experienced staff
- Utilize resource materials to manage job responsibilities
Requirements
What you’ll need- 2+ years medical claim processing experience
- Experience in a production environment
- 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