[Remote] Senior Claim Benefit Specialist at CVS Health

Minneota, Minnesota, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

At least 18 months of experience in medical claim processing
At least 18 months of experience in a production environment
High school diploma or GED

Responsibilities

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, and/or responding to complex issues
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 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
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 all cost containment measures to assist in the claim adjudication process

Skills

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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