Senior Claim Benefit Specialist

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.

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 pre‑approval/pre‑authorization, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and all payments are made in accordance with 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
• 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 Associate’s degree or equivalent work experience.

40

Full time

$18.50 – $42.35 per hour. Eligible for CVS Health bonus, commission or short‑term incentive program in addition to the base pay.

We offer a comprehensive mix of pay and benefits to support physical, emotional and financial wellness, including:

• Affordable medical plan options, a 401(k) plan (with matching contributions), and an employee stock purchase plan.
• No‑cost wellness programs: screenings, tobacco cessation, weight management, confidential counseling and financial coaching.
• Benefit solutions addressing different needs: paid time off, flexible schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and more.

Closing date: 02/27/2026.

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