Claim Benefit Specialist – Commercial Operations

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🔥 0 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

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Handle and process Benefits claims submitted by healthcare providers • Determine benefit eligibility and coverage based on insurance plans and policy guidelines • Assess claims for accuracy, medical necessity, coding compliance, and documentation requirements • Document claim information, codes, modifiers, and data elements in company systems • Conduct reviews and investigations requiring additional scrutiny or validation • Communicate with healthcare providers, patients, and stakeholders to resolve discrepancies • Ensure claims processing complies with regulatory requirements, industry standards, and company policies • Develop and implement feedback and formal performance review processes • Analyze claims data and generate reports to identify trends and improvement areas • Review and adjudicate claims according to processing guidelines • Apply medical necessity guidelines, verify eligibility, identify discrepancies, and apply cost containment measures • Review claim or referral submissions and apply coding, member identification, and provider selection processes • Analyze and process rework claims that cannot be auto-adjudicated • Manage route lists and queues according to operational guidelines • Use applicable system functions to ensure accurate and timely claim processing

🎯 Requirements

• 1–2 years of experience working in Customer Service • Strong teamwork and organizational skills • Strong and effective communication skills • Ability to handle multiple assignments competently through time management • Ability to work accurately and efficiently • 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 • High School diploma, GED or equivalent Experience

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility • Virtual training for 12–20 weeks • Flexible schedule available after successful ramp up

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