Claim Benefit Specialist Ops

CVS Health

1d • $17 - $31 • 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. Position Summary Performs claim documentation review, verifies policy coverage, assesses claim validity, 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 and members, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Follow established protocols, standards, and policies to ensure effective and timely claim processing. Determines the eligibility and coverage of benefits for each claim based on the member’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, members, or other stakeholders to resolve any discrepancies or issues related to claims. We support a hybrid work environment. If selected and you live near a suitable work location, you may be expected to comply with the hybrid work policy. Under the policy, all hires for in-scope populations should be placed into a hybrid or office-based location, working onsite three days a week. Aetna Service Operations office/hub locations will be discussed with the selected candidate.

Requirements

• Possess strong teamwork skills.
• Ability to work independently and manage multiple priorities.
• Excellent analytical, organizational, and communication skills.
• Ability to handle multiple assignments competently through use of time management, accurately and efficiently.
• Strong proficiency using computers, experience with data entry.
• Able to identify service problems and initiate appropriate actions for quick resolutions.
• A commitment to excellence and a work ethic that demonstrates our dedication to our customers.
• Uses available tools and systems to deliver timely & accurate service.
• High school diploma or equivalent required

Nice To Haves

• Experience in a production environment.
• Healthcare experience.
• Knowledge of utilizing multiple systems at once to resolve complex issues.
• Claim processing experience preferred.
• Understanding of medical terminology.
• Familiarity with healthcare regulations and compliance standards
• Familiarity with systems such as GIAS, EWM, ECHS, ePolicies, Med Compass, Strategic Contract Manager, and SIM

Responsibilities

• Handles and processes benefits claims submitted by healthcare providers and members, ensuring accuracy, efficiency, and strict adherence to policies and guidelines.
• Follow established protocols, standards, and policies to ensure effective and timely claim processing.
• Determines the eligibility and coverage of benefits for each claim based on the member’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, members, or other stakeholders to resolve any discrepancies or issues related to claims.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
• For more information, visit https://jobs.cvshealth.com/us/en/benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED