Senior Claim Benefit Specialist - Remote

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At reputed company®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Reviews and adjudicates reputed company, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to reputed company issues. May handle customer service inquiries and problems. Additional Responsibilities - Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies reputed company cost containment. measures to assist in the claim adjudication process. - Handles phone and written inquiries reputed company to requests for pre-approval/pre-authorization, reconsiderations, or appeals. - Insures reputed company compliance requirements are satisfied and reputed company payments are made against company practices and procedures. - Identifies and reports possible claim overpayments, underpayments and any other irregularities. - Performs claim rework calculations. - Distributes work assignment daily to junior staff. - Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration. Required Qualifications - 18+ months of medical claim processing experience. - Experience in a production environment. - Demonstrated ability to handle multiple assignments competently, accurately and reputed company. Preferred Qualifications - Self-Funding experience - DG system knowledge Education - High School Diploma required - Preferred Associates degree or equivalent work experience. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $18.50 - $42.35 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits This job does not have an application deadline, as reputed company accepts applications on an ongoing basis. Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They reputed company choices according to what is best for the team, they live for opportunities to collaborate and reputed company a difference, and they reputed company us the #1 Top Workplace in the area.