Senior Claim Benefit Specialist - Remote

CVS Health • South Dakota, South Dakota • 19h ago

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Position Summary

Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience.

Additional Responsibilities

Reviews pre-specified claims and those that exceed specialist adjudication authority or processing expertise.

Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost-containment measures to support accurate claim adjudication.

Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures.

Identifies and reports potential overpayments, underpayments, and other claim irregularities.

Performs claim rework calculations as needed.

Trains and mentors as needed to enhance team performance and technical proficiency.

Conducts outbound calls to obtain required information for claims or reconsideration requests.

Required Qualifications

Minimum of 18 months of medical claim processing experience with a health insurance payor or third-party administrator.

Proven success working in a high-volume, production-driven environment.

Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail.

Preferred Qualifications

Self-Funding experience

DG system knowledge

Education

- High School Diploma required

Preferred Associates degree or equivalent work experience.

Anticipated Weekly Hours

Time Type

Full time

Pay Range

The typical pay range for this role is:

$18.50 - $42.35

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments (https://learn.bswift.com/cvshealth-mainland) .

This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis.

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

CVS Health is an equal opportunity/affirmative action employer, including Disability/Protected Veteran - committed to diversity in the workplace.

Similar Jobs

Mechanical Design Engineer

Actalent • Rapid City, SD • 2min ago

IT & Engineering

Job Title: Mechanical Design Engineer Job Description This role focuses on designing and detailing sheet metal components and related mechanical systems from concept through series production, ensuring manufacturability,...

2min ago

Go to Apply

Software Development Engineer

CVS Health • South Dakota, South Dakota • 6h ago

IT & Engineering

6h ago

Go to Apply

Manufacturing Engineer

Dwyer Instruments, Inc. • Sioux Falls, SD • 19h ago

IT & Engineering

Summary: DwyerOmega is seeking an experienced "hands-on" Manufacturing Engineer to be a key team member within the Operations team. Candidate must have a proven track record of engineering support within a manufacturing...

19h ago

Go to Apply

Principal Core Infrastructure Engineer

Oracle • Pierre, SD • 1d ago

IT & Engineering

Job Description As a Principal Core Infrastructure Engineer (AI/ML Forward Deployed Infrastructure Engineer), you will play a critical role in designing, implementing, and maintaining the infrastructure that supports our...

1d ago

Go to Apply

iOS Software Engineer

Ford Motor Company • Pierre, SD • 1d ago

IT & Engineering

We made history and now we work to transform the future - for our customers, our communities and our families. You'll see your work on the road every day, helping people move freely and pursue their dreams. At Ford, you...

1d ago

Go to Apply

Lead Software Engineer, Full Stack - Shopping (Remote)

Capital One • Pierre, SD • 1d ago

IT & Engineering

Lead Software Engineer, Full Stack - Shopping (Remote) Do you love building and pioneering in the technology space? Do you enjoy solving complex business problems in a fast-paced, collaborative, inclusive, and iterative...

1d ago

Go to Apply

Senior Manufacturing Engineer

Viavi Solutions • Rapid City, SD • 1d ago

IT & Engineering

Summary: VIAVI (NASDAQ: VIAV) is a global provider of network test, monitoring and assurance solutions for telecommunications, cloud, enterprises, first responders, military, aerospace, and railway. VIAVI is also a leade...

1d ago

Go to Apply

Electrical Engineer 3

CDM Smith • Pierre, SD • 2d ago

IT & Engineering

Company Overview Check out this video and find out why our team loves to work here! ( https://www.cdmsmith.com/resources/videos/meet-cdm-smith ) Join Us! CDM Smith - where amazing career journeys unfold. Imagine a place...

2d ago

Go to Apply

Electrical Engineer 3

CDM Smith • Aberdeen, SD • 2d ago

IT & Engineering

2d ago

Go to Apply

Senior Android Software Engineer

Eliassen Group • Pierre, SD • 2d ago

IT & Engineering

Senior Android Software Engineer Anywhere Type: Contract Category: Engineer Industry: Communications Workplace Type: Remote Reference ID: JN -072026-107897 Date Posted: 07/13/2026 Shortcut: http://careers.eliassen.com/zv...

2d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)