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Senior Claims Benefit Specialist
| Company | CVS Health |
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| Location | Minnesota, USA |
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| Salary | $18.5 – $38.82 |
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| Type | Full-Time |
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| Degrees | |
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| Experience Level | Senior |
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Requirements
- 2+ years medical claim processing experience.
- 1-2 years Experience in a production/ metrics based environment
- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
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.
Preferred Qualifications
- Self-Funding experience
- DG system knowledge
