Claim Benefit 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

• Reviews and adjudicates claims in accordance with claim processing guidelines.

• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.

• Review claims or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.

• Analyzes and approves rework claims that cannot be auto adjudicated.

• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor).

• Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).

Required Qualifications

• 1-2 years working in customer service.

• Possess strong teamwork and organizational skills.

• Strong and effective communication skills.

• Ability to handle multiple assignments competently through use of time management, accurately and efficiently.

Preferred Qualifications

• Experience in a production environment.

• Knowledge of utilizing multiple systems at once to resolve complex issues.

• Claim processing experience preferred but not required.

• Understanding of medical terminology.

Education

High School diploma, GED or equivalent Experience.

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.