Encounters - Sr Claim Benefit Specialist

Job DescriptionPosition is anywhere in US -Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. -Acts as a subject matter expert by providing training, coaching, or responding to complex issues-Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise-Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process-Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures-Identifies and reports possible claim over payments, underpayments and any other irregularities-Performs claim re-work calculations-Distributes work assignments daily to junior staff-Trains and mentors claim benefit specialists-Makes outbound calls to obtain required information for First claim or re-consideration-Works with Health Plan Operations and within the State Encounter system to research and resolve errorsRequired Qualifications-Experience in a production environment-Demonstrated ability to handle multiple assignments competently, accurately and efficiently-2+ years Medical Claim processing experienceCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred QualificationsExperience in updating or developing standard operating procedures when new edits presentedMedicaid experience preferredEducationAssociate's degree or equivalent work experienceBusiness OverviewBring your heart to CVS HealthEvery 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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15