Senior Claim Benefit Specialist Operations (Encounters)

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
The Senior Claim Benefit Specialist (Encounter Corrections Analyst) researches, reviews, and adjudicates complex, sensitive, and specialized encounters in accordance with state-specific processing guidelines. This role requires medical claims processing experience and may involve supporting multiple Medicaid plans. Specialists correct encounters accurately and efficiently in a fast-paced production environment.

Drive timely resolution of encounter errors using available resources, tools, and research.

• Adjudicate complex, sensitive, and specialized claims with accuracy in the claims processing system.
• Consistently meet quality and production expectations.
• Identify and escalate issues that impact claim payment accuracy or create rework.
• Partner cross-functionally to resolve barriers to encounter acceptance.
• Contributes to the development of desktops and standardized procedures.
• Balance competing priorities while supporting multiple markets.
• Engage in working sessions and meetings that advance business objectives and Key Performance Indicators (KPI).

Required Qualifications

• Minimum 2 years of medical claims processing experience (Commercial, Medicaid, Medicare).
• Experience working in a production environment.
• Strong analytical and problem-solving skills, especially in researching claims.
• Proficiency in MS Office Suite applications; Excel, Word, OneNote
• Ability to work independently and as a team.

Preferred Qualifications

• QNXT or Facets claims processing experience.
• Experience in Medicaid or Medicare claims.
• Encounters experience.
• Edifecs system knowledge.

Education
High School Diploma

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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