Hispanic Alliance for Career Enhancement
Senior Claim Benefit Specialist
Hispanic Alliance for Career Enhancement, Phila, Pennsylvania, United States
At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose‑driven colleagues—caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. We do it all with heart, each and every day.
Position Summary Review and adjust SF (self‑funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicate complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Process provider refunds and returned checks. May handle customer service inquiries and problems.
Key Responsibilities
Perform adjustments across all dollar‑amount levels on customer service platforms by using technical and claims processing expertise.
Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost‑containment measures to assist in the claim adjudication process.
Perform claim re‑work calculations.
Follow through completion of claim overpayments, underpayments, and other irregularities.
Process complex non‑routine provider refunds and returned checks.
Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks.
Handle telephone and written inquiries related to requests for pre‑approvals/pre‑authorizations, reconsiderations, or appeals.
Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures.
Review and handle relevant correspondences assigned to the team that may result in adjustment to claims.
May provide job shadowing to less experienced staff.
Utilize all resource materials to manage job responsibilities.
Required Qualifications
2+ years medical claim processing experience.
Experience in a production environment.
Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
Effective communications, organizational, and interpersonal skills.
Preferred Qualifications
DG system claims processing experience.
Associate degree preferred.
Education
High School Diploma or GED.
Job Details Anticipated Weekly Hours: 40
Time Type: Full time
Pay Range: $18.50 - $42.35 per hour. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above.
Benefits We take pride in our comprehensive and competitive mix of pay and benefits—investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options,
a
401(k) plan
(including matching company contributions), and an
employee stock purchase plan.
No‑cost programs for all colleagues
including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues
including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
Legal Notice Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Application Window We anticipate the application window for this opening will close on: 12/23/2025.
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Position Summary Review and adjust SF (self‑funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicate complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Process provider refunds and returned checks. May handle customer service inquiries and problems.
Key Responsibilities
Perform adjustments across all dollar‑amount levels on customer service platforms by using technical and claims processing expertise.
Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost‑containment measures to assist in the claim adjudication process.
Perform claim re‑work calculations.
Follow through completion of claim overpayments, underpayments, and other irregularities.
Process complex non‑routine provider refunds and returned checks.
Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks.
Handle telephone and written inquiries related to requests for pre‑approvals/pre‑authorizations, reconsiderations, or appeals.
Ensure all compliance requirements are satisfied and that all payments are made following company practices and procedures.
Review and handle relevant correspondences assigned to the team that may result in adjustment to claims.
May provide job shadowing to less experienced staff.
Utilize all resource materials to manage job responsibilities.
Required Qualifications
2+ years medical claim processing experience.
Experience in a production environment.
Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
Effective communications, organizational, and interpersonal skills.
Preferred Qualifications
DG system claims processing experience.
Associate degree preferred.
Education
High School Diploma or GED.
Job Details Anticipated Weekly Hours: 40
Time Type: Full time
Pay Range: $18.50 - $42.35 per hour. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above.
Benefits We take pride in our comprehensive and competitive mix of pay and benefits—investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options,
a
401(k) plan
(including matching company contributions), and an
employee stock purchase plan.
No‑cost programs for all colleagues
including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues
including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
Legal Notice Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Application Window We anticipate the application window for this opening will close on: 12/23/2025.
#J-18808-Ljbffr