Review and adjudicate complex and sensitive claims while serving as a subject matter expert.
About CVS Health
CVS Health is the nation’s leading health solutions company, serving millions of Americans through local presence, digital channels, and over 300,000 colleagues. Our mission is to deliver connected, compassionate, and convenient care where and when people need it.
Schedule
- Full-time, 40 hours per week
- Remote – available in 50 states
- Application window closes: October 31, 2025
What You’ll Do
- Review and adjudicate complex claims in line with plan processing guidelines.
- Apply medical necessity guidelines, verify eligibility, and ensure cost containment measures.
- Handle phone and written inquiries related to pre-approvals, reconsiderations, or appeals.
- Identify and report potential overpayments, underpayments, and irregularities.
- Perform claim rework calculations and distribute assignments to junior staff.
- Train, mentor, and support claim benefit specialists.
- Make outbound calls to gather information for claims or reconsiderations.
What You Need
- Minimum 18 months of medical claim processing experience.
- Background in a production environment.
- Ability to manage multiple assignments with accuracy and efficiency.
Preferred Qualifications
- Experience with self-funded plans.
- Familiarity with DG system.
Education
- High School Diploma required.
- Associate degree or equivalent experience preferred.
Pay Range
- Hourly rate: $18.50 – $42.35
- Eligible for CVS Health bonus, commission, or incentive programs.
Benefits
- Affordable medical plan options, 401(k) with company match, employee stock purchase plan.
- Paid time off, flexible schedules, family leave, dependent care resources.
- Wellness programs, counseling, financial coaching, tuition assistance, retiree medical access (eligibility varies).
CVS Health is an Equal Opportunity Employer, including Disability/Protected Veteran status. We are committed to building a diverse and inclusive workplace where every colleague feels valued.
Happy Hunting,
~Two Chicks…