Claim Benefit Specialist Medical Review

CVS Health•Franklin, TN

2d•Onsite

About The Position

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.

Requirements

Must report into Franklin, TN office Tuesday- Thursday
Experience in a high production environment
Experience with Microsoft Office
Ability to review and triage documents to the correct location
Ability to multi-task, prioritize, & handle multiple workloads/assignments
Ability to collaborate with team members to resolve any issues

Nice To Haves

1-2 years’ experience reviewing medical records
Medical coding knowledge

Responsibilities

Performs medical claims review by ordering and evaluating medical records, verifying policy coverage, and assessing health conditions against policy requirements and application disclosures to determine claim validity.
Communicates effectively with healthcare providers, policyholders, and beneficiaries to ensure timely and accurate processing of medical and final expense claims.
Contributes to efficient claim handling through strong knowledge of medical record review processes, policy interpretation, and team collaboration.
Orders, handles and reviews medical records for contestable claims, ensuring accuracy, efficiency, and adherence to policies and guidelines.
Determines the eligibility and coverage of benefits for each policy based on the patient's insurance plan, health conditions, the scope of coverage, and policy guidelines.
Documents claim with medical records information in the system, assigning appropriate codes and other necessary data elements to ensure accurate tracking, reporting, and processing of claims in all appropriate applications.
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 medical review activities comply with regulatory requirements, industry standards and company policies.
Provides regular, timely feedback to frontline claims analysts to drive effective delivery of exceptional services and competencies.