Claim Specialist

• Review and adjudicate complex, sensitive, and specialized medical claims according to established plan processing guidelines
• Serve as a subject matter expert by providing 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 confirm payments align with company policies and procedures
• Identify and report potential overpayments, underpayments, and other claim irregularities
• Perform claim rework calculations
• Train and mentor as needed
• Conduct outbound calls to obtain required information for claims or reconsideration requests

Explore Senior Claim Benefit Specialist at CVS Health Careers. Review requirements and application details.