Claim Benefit Specialist – Commercial Operations

Job not on LinkedIn

🔥 3 minutes ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

💵 $17 - $25 / hour

⏰ Full Time

🟢 Junior

⚙️ Operations

🚫👨‍🎓 No degree required

👻 Ghost score 0%

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and adherence to policies and guidelines. • Determines eligibility and coverage of benefits based on insurance plans and policy guidelines. • Assesses claims for accuracy, coding compliance, medical necessity, and documentation requirements. • Documents claim information, codes, modifiers, and data elements in company systems. • Conducts reviews and investigations requiring additional scrutiny or validation. • Communicates with healthcare providers, patients, and stakeholders to resolve claim discrepancies. • Ensures claims processing complies with regulatory requirements, industry standards, and company policies. • Reviews and adjudicates claims according to processing guidelines. • Applies medical necessity guidelines, verifies eligibility, identifies discrepancies, and applies cost containment measures. • Reviews claims or referral submissions and applies coding, member identification, provider selection, and pre-coding requirements. • Analyzes and processes rework claims that cannot be auto-adjudicated. • Manages route lists and queues according to operational guidelines. • Uses applicable system functions to ensure accurate and timely claim processing. • Analyzes claims data and generates reports to identify trends and improvement areas. • Develops and implements feedback and formal performance review processes to support service delivery, engagement, motivation, and team development.

🎯 Requirements

• 1-2 years experience 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 • High School diploma, GED or equivalent Experience • Experience in a production environment (preferred) • Healthcare experience (preferred) • Knowledge of utilizing multiple systems at once to resolve complex issues (preferred) • Claim processing experience preferred but not required • Understanding of medical terminology (preferred)

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being

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