Claim Benefit Specialist – Commercial Operations

Job not on LinkedIn

🔥 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 benefits eligibility and coverage based on insurance plans and policy guidelines • Assess claims for accuracy, medical necessity, coding compliance, and documentation requirements • Document claim information and assign appropriate codes, modifiers, and data elements • Conduct reviews and investigations requiring additional scrutiny or validation • Communicate with healthcare providers, patients, and stakeholders to resolve claim discrepancies • Ensure claims processing complies with regulatory requirements, industry standards, and company policies • Provide regular, timely feedback and participate in formal performance reviews and team development • Analyze claims data and generate reports identifying trends, patterns, 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 referrals and 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, 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) • Ability to complete 12–20 weeks of virtual training, 8:00–4:30 EST • Ability to work 40 hours per week

🏖️ Benefits

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