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.
Position SummaryThe Provider Data Services Specialist for the Claim Pend team, is responsible for researching, analyzing, and resolving provider-related claim pends to ensure timely and accurate claims adjudication. This role focuses on resolving pended claims caused by provider data, contract, affiliation, or configuration of issues within claims and provider systems. The analyst partners closely with internal Provider Data, Claims, Quality, and Implementation teams to reduce inventory aging, meet turnaround time (TAT) requirements, and maintain compliance with state Medicaid guidelines.
Key Responsibilities- Research and resolve provider-related claim pends using internal systems (e.g., claims and provider modules).
- Analyze pend root causes related to provider enrollment, contracting, affiliations, specialties, pay-to relationships, and configuration issues.
- Update provider records and/or route claims appropriately to allow claims to continue through adjudication.
- Apply state-specific Medicaid requirements and business rules when resolving claims.
- Document actions clearly and accurately in claim memos and tracking tools.
- Manage assigned inventory daily, prioritizing aged and high-impact claims to meet established TAT and productivity standards.
- Identify trends in pended claims and escalate systemic issues to leadership or appropriate partners.
- Collaborate with Provider Data, Claims, Quality, Automation (BOT), and Implementation teams to improve workflows and reduce repeat pends.
- Support audit and quality review activities by providing documentation and responding to findings.
- Follow established procedures, job aids, and compliance standards.
- 1–3 years of experience in healthcare operations, claims processing, provider data, or related roles.
- Strong analytical and problem-solving skills with attention to detail.
- Ability to interpret policies, procedures, and state-specific Medicaid requirements.
- Proficiency in navigating multiple systems and tools simultaneously.
- Strong written communication skills for documentation and claim memo entry.
- Ability to manage workload independently in a production-driven environment.
Preferred Qualifications
- Experience working claim pends, provider data, enrollment, or contracting issues preferred.
- Experience supporting Medicaid or government programs.
- Familiarity with provider data systems, claims platforms, or healthcare configuration tools.
- Experience working with production metrics, quality audits, or compliance standards.
- Prior experience identifying trends or contributing to process improvements.
- High school diploma or equivalent required; associate’s or bachelor’s degree preferred.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$17.00 - $28.46This 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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
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.
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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.
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