Claims 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 Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicates 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. Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Performs claim re-work calculations. Follow through completion of claim overpayments, underpayments, and any 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. Ensures 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 adj

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. A Brief Overview Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. What you will do Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements. Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution. Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.</sp

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. A Brief Overview Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. What you will do Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements. Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution. Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.</sp

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

Work Flexibility: Remote Staff Regulatory Affairs Specialist, Mako and Enabling Technologies (Remote) Join Stryker’s Ortho Tech Business and support a portfolio that spans robotics, navigation, imaging, software, and capital equipment technologies. In this role, you will provide regulatory leadership throughout the product lifecycle, partnering with cross-functional teams to support global product development, regulatory submissions, market access, and ongoing regulatory compliance across U.S. and international markets. Work Flexibility: This is a remote position, with a preference for candidates located in the U.S. Eastern Time Zone What You Will Do Develop and execute global regulatory strategies for new products, product changes, and lifecycle management activities. Participate in product development teams to ensure U.S., European, and international regulatory requirements are incorporated throughout all development phases. Evaluate product classifications, regulatory pathways, and jurisdictional requirements for medical devices and related technologies. Author and submit regulatory filings, including FDA submissions, international registrations, and supporting documentation required for product approvals. Review quality, preclinical, and clinical documentation to ensure submission readiness and regulatory compliance. Partner with global regulatory affiliates to support registrations, market expansions, and post-market regulatory activities. Lead interactions with regulatory authorities and notified bodies, including preparation of responses, submissions, and agency communications. Review product labeling, marketing materials, and product claims for compliance with applicable regulatory requirements and mentor junior regulatory team members on regulatory

At ClickUp, we're building the future of work: the first truly converged AI workspace unifying tasks, docs, chat, calendar, and enterprise search, all supercharged by context-driven AI. We are an AI-native company. Every team member is expected to leverage AI daily, and we evaluate AI fluency as part of our hiring process. Join us and help redefine what's possible. 🚀 ClickUp is looking for a Senior Partner Sales Support Specialist based in the Philippines. This role is a critical enablement function supporting our Enterprise Partner Managers worldwide. You’ll be the operational backbone that keeps our partner sales motion running smoothly, helping Enterprise Partner Managers close deals faster by handling sales support activities across all regions. This is a high-impact, globally-scoped role that sits at the intersection of partner operations, sales enablement, and deal support. The candidate will be customer and partner-facing (on Zoom). The role: Provide day-to-day partner support to Enterprise Partner Managers across all regions (AMER, EMEA, APAC, LATAM), including deal registration processing, pipeline management, and opportunity tracking. Own and process smaller partner-sourced deals end-to-end, managing them through internal systems to ensure fast, accurate closure. Manage internal system administration (Salesforce, deal desk, CPQ) to remove friction from the partner deal cycle, including quote generation, order processing, and approval routing. Coordinate and manage partner onboarding logistics, ensuring new partners are set up in systems, trained on tools, and equipped to transact effectively. Maintain partner CRM data hygiene, ensuring accurate pipeline inputs, deal stage progression, and timely reporting for leadership. Act as the internal point of contact for partner deal escalations, liaising with Deal Desk, Legal, Finance, and RevOps to unblock and accelerate closures. Process MDF (Market Development Fund) submissions, track claims, and ensure timely