Senior Claim Benefit Specialist - Remote

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

- Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise.

- Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication.

- Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures.

- Identifies and reports potential overpayments, underpayments, and other claim irregularities.

- Performs claim rework calculations as needed.

- Trains and mentors as needed to enhance team performance and technical proficiency.

- Conducts outbound calls to obtain required information for claims or reconsideration requests.

- Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator.

- Proven success working in a high‑volume, production‑driven environment.

- Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail.

- Self-Funding experience

- DG system knowledge

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.