This is a higher-responsibility claims role: you’re adjudicating complex claims, handling appeals and reconsiderations, doing rework calculations, and acting like the “go-to” when things get messy. The big catch: you need a New York Independent Adjuster License.
About CVS Health
CVS Health delivers health solutions through its nationwide footprint and digital channels, supporting millions of members with a focus on more connected, convenient care and service.
Schedule
- Full-time, remote
- 40 hours/week
- Application window closes 02/27/2026
What You’ll Do
- Review and adjudicate complex and sensitive claims per plan guidelines
- Apply medical necessity guidelines and verify coverage and eligibility
- Identify discrepancies and apply cost-containment measures
- Handle phone and written inquiries for pre-approvals, pre-authorizations, reconsiderations, and appeals
- Ensure compliance requirements are met and payments align with policies
- Identify and report overpayments, underpayments, and other claim irregularities
- Perform claim rework calculations
- Make outbound calls to collect missing details for claims and reconsiderations
- Support the team by distributing daily work assignments to junior staff
- Train, coach, and mentor claim benefit specialists as a subject matter expert
What You Need
- New York Independent Adjuster License (required)
- Experience in a production environment
- Ability to manage multiple assignments accurately and efficiently
- High school diploma required
- Associate degree or equivalent work experience preferred
Benefits
- Medical plan options
- 401(k) with matching contributions
- Employee stock purchase plan
- Wellness programs, counseling, and financial coaching
- PTO, flexible schedules, family leave, dependent care resources, tuition assistance (varies by eligibility)
Pay
- Typical range: $18.50 – $42.35/hour (final offer depends on experience, education, geography, and other factors)
- Eligible for bonus/commission/short-term incentive programs depending on role and plan
Quick reality check: if you don’t already have that NY Independent Adjuster License, this one is basically a “not yet” job, not a “maybe” job. If you do have it, tell me what claims world you’re coming from (medical, auto, workers comp, self-funded), and I’ll help you angle your resume bullets so you don’t look like a generalist.
Happy Hunting,
~Two Chicks…