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.

Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills.

• Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines.
• Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope.
• Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements.
• Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims.
• Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution.
• Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.
• Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies.
• Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.
• Analyzes claims data and generate reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.

• Less than 1 year work experience
• Working knowledge of problem solving and decision making skills

• High school diploma or equivalent required.

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

• Analyzes and approves routine claims that cannot be auto adjudicated.
• Applies medical necessity guidelines, determines coverage, complete eligibly verification, identify discrepancies and applies all cost containment measures to assist in the claim adjudication process.
• Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
• Routes and triages complex claims to Senior Claim Benefits Specialist.
• Proofs claim or referral submission to determine, review or apply appropriate guidelines, coding, member identification process, diagnosis and pre-coding requirements.
• May facilitate training when considered topic subject matter expert.
• 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 services (i.e. utilizes claim check, reasonable and customary data, and other post‑containment tools).
• Must adhere to training schedule: 20 weeks. Monday through Friday…