Senior Claims Benefit Specialist- Work From Home

Job Description
This is a full time telework position. Qualified candidates may reside in any state (US).

The Senior Claim Benefit Specialist reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems.

Fundamental Components:
• Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
• Handles phone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.
• Identifies and reports possible claim overpayments, underpayments and any other irregularities.
• Performs claim re-work calculations.
• Distributes work assignments daily to junior staff.
• Trains and mentors claim benefit specialists.
• Makes outbound calls to obtain required information for First claim or re-consideration.
• Trained and equipped to support call center activity if required, including general member and/or provider inquiries.

Required Qualifications
• Experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• 2+ years' claim processing experience.
• Demonstrated proficiency with personal computer, keyboard navigation skills, and MS Office Suite applications.

COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.
  • If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
  • If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications
• Understanding of medical terminology.
• Strong knowledge of benefit plans, policies and procedures.
• Oral and written communication skills.
• Ability to maintain accuracy and production standards.
• Technical skills.
• Analytical skills.

Associate's degree or equivalent work experience.

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.