Claim Benefit Specialist Operations

CVS Health•Franklin, TN

5d•$17 - $28•Hybrid

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. This is a hybrid role requiring reporting to the Franklin, TN Aetna office three days a week with no exceptions. 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.

Requirements

Less than one (1) year of relevant experience in healthcare, insurance, claims processing, billing, coding, customer service, or administrative support.
Ability to read, interpret, and apply policies, procedures, and benefit plan information.
Strong attention to detail and accuracy when reviewing data, documentation, and codes.
Basic proficiency with computer systems and data entry, including the ability to learn claims processing systems and software.
Effective written and verbal communication skills, with the ability to communicate professionally with healthcare providers, policyholders, and internal teams.
Ability to manage multiple tasks, meet deadlines, and work effectively in a fast‑paced, production‑oriented environment.
Ability to work independently and collaboratively as part of a team.

Nice To Haves

Familiarity with medical billing, claims processing, or healthcare terminology.
Experience working with highly confidential or regulated information.
Prior experience in a healthcare, insurance, or customer service environment.
Comfortable working in a hybrid work environment.
Some experience in a highly regulated, fast pace environment.

Responsibilities

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.