Job Description
Sr Claim Benefit Specialist
Job ID: R0020444
Category: Plan Operations
Address:
Location: Saint Paul, MN
Remote: Remote
Salary: 18.50 – 36.30 /hour
Job Description:
Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand with heart at its center our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
Position Summary
- Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems.
- Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
- – Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment. measures to assist in the claim adjudication process.
- – Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.
- – Insures all compliance requirements are satisfied and all payments are made against company practices and procedures.
- – Identifies and reports possible claim overpayments, underpayments and any other irregularities.
- – Performs claim rework calculations.
- – Distributes work assignment daily to junior staff.
- – Trains and mentors claim benefit specialists.
- – Makes outbound calls to obtain required information for claim or reconsideration.
Required Qualifications
- – 2+ years claim processing experience.
- – Experience in a production environment.
- – Claim processing experience.
- – Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
Preferred Qualifications
- – Associates degree
Education
Associates degree or equivalent work experience.