Senior Claim Benefit Specialist
CVS Pharmacy - Minneapolis, MN
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Job DescriptionReviews 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.Other duties includes:- 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.Pay RangeThe typical pay range for this role is:Minimum: 18.50Maximum: 34.60Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required Qualifications- Experience in a production environment- Demonstrated ability to handle multiple assignments competently, accurately and efficiently- 1+ years Claim processing experience- General Business/Maximizing Work- Excellent verbal and written communication skills- Proficient use Microsoft Office applications, e.g. Excel, WordPreferred Qualifications- 2+ years claim processing experience. - Experience in a production environment.- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.Education- Associates degree or equivalent work experience.Business OverviewBring 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. 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. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
Created: 2024-09-07