If you can adjudicate complex claims, catch discrepancies before they become problems, and keep production quality high under pressure, this role is a strong fit. You’ll serve as a go-to expert for sensitive or specialized claims while supporting inquiries, mentoring others, and helping protect accuracy and compliance.
About CVS Health
CVS Health is building a more connected, convenient, and compassionate healthcare experience nationwide. With a broad national footprint across health benefits, pharmacy, and care services, CVS supports members and providers while continuously improving how care is accessed and paid for.
Schedule
- Fully remote
- Full-time: 40 hours per week
- Production environment with daily claim work assignments
- No application deadline (open until filled)
What You’ll Do
⦁ Review and adjudicate complex, sensitive, and specialized medical claims based on plan processing guidelines
⦁ Apply medical necessity guidelines, determine coverage, verify eligibility, and resolve discrepancies
⦁ Apply cost containment measures as part of the adjudication process
⦁ Handle phone and written inquiries related to pre-approvals, pre-authorizations, reconsiderations, and appeals
⦁ Ensure compliance requirements are met and payments align with company practices and procedures
⦁ Identify and report potential overpayments, underpayments, and other claim irregularities
⦁ Perform claim rework calculations when adjustments are needed
⦁ Distribute daily work assignments to junior staff and support production flow
⦁ Train and mentor claim benefit specialists, sharing expertise and best practices
⦁ Make outbound calls to obtain required information for claims or reconsiderations
What You Need
⦁ 18+ months of medical claim processing experience
⦁ Experience working in a production environment
⦁ Proven ability to handle multiple assignments accurately, efficiently, and consistently
⦁ High school diploma required (Associate’s degree or equivalent work experience preferred)
Benefits
⦁ Pay range: $18.50 to $42.35 (varies by experience, location, and qualifications)
⦁ Affordable medical plan options and 401(k) with company match
⦁ Employee stock purchase plan eligibility
⦁ No-cost wellness programs plus confidential counseling and financial coaching
⦁ Paid time off, flexible work schedules, family leave, tuition assistance, and other benefits based on eligibility
Hiring is ongoing. If your claims experience is solid and you’re ready to operate at a senior level, go ahead and move on it.
This is a “details matter” role. The right person saves time, money, and headaches across the board.
Happy Hunting,
~Two Chicks…