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.
A Brief Overview
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.
What you will do
- 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.
Position Summary
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.
Required Qualifications
- 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
Preferred Qualifications
- 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.
Education
- High School diploma, GED or equivalent Experience
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$17.00 - $25.65This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Skills Required
- 1-2 years of customer service experience
- Strong teamwork and organizational skills
- Strong and effective communication skills
- Ability to manage multiple assignments using time management accurately and efficiently
- High school diploma, GED, or equivalent experience
- Experience in a production environment
- Healthcare experience
- Experience utilizing multiple systems simultaneously to resolve complex issues
- Claim processing experience
- Understanding of medical terminology
CVS Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CVS Health and has not been reviewed or approved by CVS Health.
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Healthcare Strength — Health coverage includes medical, dental, and vision with HSA-eligible options, free preventive care, virtual care, and access to MinuteClinic services. Mental-health resources such as counseling support are emphasized, and coverage is often considered solid for full-time colleagues.
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Retirement Support — A dollar-for-dollar 401(k) match up to 5% after one year and an Employee Stock Purchase Plan are consistently highlighted in Total Rewards materials. Feedback suggests retirement programs are a meaningful strength within the overall package.
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Wellbeing & Lifestyle Benefits — Wellbeing offerings include up to 20 no-cost counseling sessions per issue, backup care, tuition assistance, and substantial in-store discounts, alongside broader wellness tools. These everyday perks expand value beyond base pay and can be especially meaningful for full-time schedules.
CVS Health Insights
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
