Senior Claim Benefit Specialist - Remote
Remote · USFull-time$18.5–42.35/hrPosted 5 days agoStill listed 4 days ago
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At a glance
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Job overview
The Senior Claim Benefit Specialist reviews and adjudicates complex medical claims under established plan guidelines. The role provides coaching and guidance on escalated issues and supports customer service by addressing inquiries and resolving member issues. It also applies medical necessity guidelines, verifies eligibility and coverage, identifies claim irregularities, performs rework calculations, and makes outbound calls to obtain information.
Skills & qualifications
Skills
Qualifications
Benefits
Full job description
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 40
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.
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.
How this job compares
Set against the 515 open Claims Specialist jobs on Olive Jobs, counted November 10, 2026.
- Pay
- This posting$18.5–42.35/hr
- US median$20–30/hr49 hourly ranges
This range's midpoint, $30.43/hr, is 30% above the US median midpoint ($23/hr) — in the top quarter of Claims Specialist hourly ranges across the US.
- Openings
- Olive Jobs lists 23 open Claims Specialist jobs in Georgia and 515 across the US. 19% of them nationwide are listed as remote or flexible.
- Hiring the most in Georgia
- The Hartford6 open
- AIG4 open
- Axis3 open
- Experience
- This posting asks for at least 1 year of experience — less than three in four Claims Specialist postings that state a minimum ask for (median 5 years, across 446 postings).
- Education
- This posting asks for a high school diploma; 234 of the 515 open Claims Specialist jobs (45%) ask for a high school diploma or higher.
Counted across the open, public US postings on Olive Jobs on November 10, 2026. Pay medians are the middle values of the low ends and of the high ends of postings that list both ends of a range in the same cadence (a yearly salary or an hourly rate); a range's midpoint is halfway between its ends. Pay and experience figures resting on fewer than 20 postings are left out.
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