This is for the people who don’t flinch at complex claims and messy situations. You’ll be the steady hand reviewing sensitive, specialized claims, catching errors before they become problems, and helping the team stay sharp.
About CVS Health
CVS Health is a leading health solutions company serving millions through local presence and digital channels. This role supports accurate and compliant claim decisions while helping improve consistency across the claims operation.
Schedule
- Remote (available in 49 locations)
- Full-time, 40 hours/week
- Ongoing posting (no application deadline listed)
What You’ll Do
⦁ Review and adjudicate complex, sensitive, and/or specialized medical claims using plan guidelines
⦁ Apply medical necessity guidelines, confirm coverage and eligibility, and use cost containment measures
⦁ Handle phone and written inquiries tied to pre-approvals, reconsiderations, and appeals
⦁ Ensure compliance requirements are met and payments align with company practices
⦁ Identify and report overpayments, underpayments, and other claim irregularities
⦁ Perform claim rework calculations and outbound calls to gather missing information
⦁ Distribute daily work assignments to junior staff
⦁ Train and mentor Claim Benefit Specialists and support the team as a subject matter expert
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 degree or equivalent experience preferred)
Benefits
⦁ Affordable medical plan options
⦁ 401(k) with company match and employee stock purchase plan
⦁ Wellness programs, confidential counseling, and financial coaching
⦁ Paid time off, flexible schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access, and more (eligibility varies)
This posting is “open-ended,” which sounds comfy… but don’t get cute. These roles can close fast once they hit their hiring numbers.
If you’ve got at least 18 months of claims processing and you’re ready to be the go-to on the hard stuff, go apply.
Happy Hunting,
~Two Chicks…