Claim Benefit Specialist- Commercial Operations

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.

This is a Claim Benefit Specialist position and will be trained for 20 weeks virtually.

• Training: 12-20 Weeks 8:00-4:30 EST Virtual
• Shift hours:
  Flex schedule available after successful ramp up
• Reviews and adjudicates claims in accordance with claim processing guidelines.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
• Review claims or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.
• Analyzes and processes rework claims that cannot be auto adjudicated.
• In accordance with prescribed operational guidelines, manages route list/queues.
• Utilizes all applicable system functions available ensuring accurate and timely claim processing service.

• 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

• Experience in a production environment.
• Healthcare experience.
• Knowledge of utilizing multiple systems at once to resolve complex issues.
• Claim processing experience preferred but not required.
• Understanding of medical terminology.

• High School…