Senior Claim Benefit Specialist - Pharmacy (RX)

CVS Health Pharmacy Claim Specialist

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

Responsible for researching, reviewing, and correcting pharmacy-related claim issues to ensure accurate benefit administration, financial accuracy, and compliance with client and regulatory requirements. The role requires strong analytical skills, attention to detail, and the ability to work independently while meeting productivity and quality expectations.

Executes both routine and non-routine business support tasks for the Claim Benefit area under limited supervision, referring deviations from standard practices to managers.

Follows area protocols, standards, and policies to provide effective and timely support.

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

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

Required Qualifications

• 2+ experience in a production environment.
• 2+ years medical claim processing experience.

Preferred Qualifications

• Knowledge of pharmacy claims, benefits, and adjustment processes.
• Attention to detail and accuracy.
• Strong analytical and problem-solving skills.
• Ability to interpret data from reports and spreadsheets.
• Effective written and verbal communication skills.
• Ability to manage multiple priorities and work independently.
• DG system claims processing experience.

Education

• Associate degree or equivalent experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

$18.50 - $38.82

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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

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.