If you’re strong in medical claim adjudication and you like being the person people go to when things get complex, this role puts you in the driver’s seat. You’ll work high-impact claims work while supporting quality, compliance, and smoother outcomes for members.
About CVS Health
CVS Health is building a more connected, convenient, and compassionate health care experience. With nationwide reach and purpose-driven teams, they focus on improving access, affordability, and outcomes for individuals and communities.
Schedule
- Full-time (40 hours/week)
- Remote
What You’ll Do
- Review and adjudicate complex, sensitive, and specialized medical claims based on plan guidelines
- Apply medical necessity guidelines, verify eligibility, identify discrepancies, and apply cost containment measures
- Handle phone and written inquiries tied to pre-approvals, pre-authorizations, reconsiderations, and appeals
- Ensure compliance requirements are met and payments align with company policies and procedures
- Identify and report potential overpayments, underpayments, and claim irregularities
- Perform claim rework calculations and outbound calls to gather needed documentation
- Support team workflow by distributing daily work assignments to junior staff
- Train and mentor claim benefit specialists and assist with complex issue resolution
What You Need
- 18+ months of medical claim processing experience
- Experience working in a production environment
- Ability to manage multiple assignments accurately and efficiently
- High School Diploma (Associate’s degree preferred or equivalent experience)
Benefits
- Competitive pay range: $18.50–$42.35 per hour (based on experience, location, and other factors)
- Medical plan options
- 401(k) with matching contributions
- Employee stock purchase plan
- Wellness programs, counseling, and financial coaching
- Paid time off and additional leave options (varies by eligibility)
- Tuition assistance and additional benefit offerings (varies by eligibility)
If you’ve got solid claims experience and you’re ready to step into more complex work, this is one to move on now.
Happy Hunting,
~Two Chicks…