Claim Benefit Specialist – Commercial Operations

Job not on LinkedIn

🔥 0 minutes ago

🏈 Alabama, Alaska, +44 more states – Remote

🏈 Alabama – Remote 🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🌺 Hawaii – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $17 - $28 / 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 eligibility and coverage based on insurance plans and policy guidelines • Assess claims for accuracy, coding compliance, medical necessity, and documentation requirements • Document claim information, codes, modifiers, and other 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 • Provide feedback and participate in formal performance reviews to support service delivery and team development • Analyze claims data and generate reports identifying 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 claims or referrals and apply coding, member identification, provider selection, and pre-coding 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 • Complete 12–20 weeks of virtual training from 8:00–4:30 EST

🎯 Requirements

• 1–2 years experience working in Customer Service • 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, based on eligibility • Virtual training for 12–20 weeks • Flex schedule available after successful ramp up