If you’re sharp with medical claims and you don’t panic when things get messy, this role is basically “high-complexity claims + SME support + light leadership.” You’ll adjudicate sensitive/specialized claims, handle escalations, and help guide junior folks while staying compliant and accurate.
About CVS Health
CVS Health is focused on building a more connected, convenient, and compassionate health experience for consumers, backed by a large national footprint and enterprise-scale operations.
Schedule
- Full-time (40 hours/week)
- Remote
- Application window expected to close: 02/27/2026
What You’ll Do
- Review and adjudicate complex or sensitive claims using plan processing guidelines
- Apply medical necessity guidelines, verify eligibility, spot discrepancies, and use cost containment measures
- Handle phone and written inquiries for pre-approvals, pre-authorizations, reconsiderations, and appeals
- Ensure compliance requirements are met and payments align with company practices and procedures
- Identify and report irregularities (overpayments, underpayments, other red flags)
- Perform claim rework calculations
- Distribute daily work assignments to junior staff
- Train and mentor Claim Benefit Specialists
- Make outbound calls to gather missing information for claims or reconsiderations
What You Need
- New York Independent Adjuster License (required)
- Experience working in a production environment
- Ability to handle multiple assignments accurately, efficiently, and consistently
Preferred Qualifications
- 18+ months of medical claim processing experience
- Self-funded plan experience
- DG system knowledge
Benefits
- Pay range: $18.50–$42.35/hour (actual offer varies by experience, location, etc.)
- Eligible for CVS Health bonus/short-term incentives (in addition to base pay)
- Medical plan options, 401(k) with company match, employee stock purchase plan
- No-cost wellness programs, counseling, and financial coaching
- PTO, flexible schedules, family leave, tuition assistance, and more (eligibility varies)
Here’s the “don’t waste your time” filter: if you don’t already have the New York Independent Adjuster License, you’re dead in the water for this one. If you do have it, this could be a solid remote lane.
Happy Hunting,
~Two Chicks…