Job Description & Responsibilities:
Position Summary 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. 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 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. - Insures 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.
Qualifications
Required Qualifications - 18+ months of medical claim processing experience. - Experience in a production environment. - Demonstrated ability to handle multiple assignments competently, accurately and efficiently. Preferred Qualifications - Self-Funding experience - DG system knowledge Education - High School Diploma required - Preferred Associates degree or equivalent work experience.
Salary:
$18.50 - $42.35
Contact:
Employer: CVS Health
Location: REMOTE
Link: https://jobs.cvshealth.com/us/en/job/R0796505/Senior-Claim-Benefit-Specialist-Remote