Senior Claim Benefit Specialist

Join to apply for the Senior Claim Benefit Specialist role at CVS Health

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems.

• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
• Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and all payments are made against company practices and procedures.
• Identifies and reports possible claim over payments, 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.

• New York Independent Adjuster License
• Experience in a production environment.
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Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

• 18+ months of medical claim processing experience
• Self-Funding experience
• DG system knowledge

• High School Diploma required
• Preferred Associates degree or equivalent work experience.

40

Full time

$18.50 - $42.35 per hour.

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all 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.

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We anticipate the application window for this opening will close on: 02/27/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

• Mid-Senior level

• Full-time

• Human Resources

• Hospitals and Health Care