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Encounters - Senior Claim Benefit Specialist

Company: CVS Health
Location: Tallahassee
Posted on: August 4, 2022

Job Description:

Job Description

Position is anywhere in US

* 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
* 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
* Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures
* Identifies and reports possible claim over payments, 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
* Works with Health Plan Operations and within the State Encounter system to research and resolve errors

Required Qualifications

* Experience in a production environment
* Demonstrated ability to handle multiple assignments competently, accurately and efficiently
* 2+ years Claim processing experience

COVID Requirements

COVID-19 Vaccination Requirement

CVS Health requires certain colleagues 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, religious belief, or other legally recognized reasons that prevents them from being 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 or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Preferred Qualifications

Experience in updating or developing standard operating procedures when new edits presented


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.

Keywords: CVS Health, Tallahassee , Encounters - Senior Claim Benefit Specialist, Other , Tallahassee, Florida

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