[Remote] Senior Claim Benefit Specialist - Remote

Note: The job is a remote job and is open to candidates in USA. CVS Health is the nation’s leading health solutions company, dedicated to transforming health care. They are seeking a Senior Claim Benefit Specialist who will review and adjudicate complex claims, provide training and support to junior staff, and ensure compliance with processing guidelines. Responsibilities • 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 Skills • 18+ months of medical claim processing experience • Experience in a production environment • Demonstrated ability to handle multiple assignments competently, accurately and efficiently • High School Diploma required • Self-Funding experience • DG system knowledge • Preferred Associates degree or equivalent work experience Benefits • Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. Company Overview • CVS Health is a health solutions company that provides an integrated healthcare services to its members. It was founded in 1963, and is headquartered in Woonsocket, Rhode Island, USA, with a workforce of 10001+ employees. Its website is Apply tot his job