Claim Benefit Specialist

CVS Health•Work At Home-Arizona, AZ

1d•$17 - $34

About The Position

The Claim Benefit Specialist reviews and adjudicates routine medical claims in accordance with claim-processing guidelines. The role reviews claim documentation, verifies policy coverage and eligibility, assesses claim validity and medical necessity, and supports accurate, timely reimbursement processing. The specialist documents claims in company systems, applies appropriate codes and modifiers, and follows regulatory requirements, industry standards, and company policies. The position analyzes and approves routine claims that cannot be automatically adjudicated, applies cost-containment measures, resolves routine claim discrepancies through communication with providers, patients, and other stakeholders, and routes complex claims to a Senior Claim Benefits Specialist. It also handles routine phone inquiries and written correspondence, manages claims and queues within turnaround-time parameters, and may facilitate training as a subject matter expert. The role also analyzes claims data and generates reports to identify trends and opportunities for process improvement. Training is scheduled for 20 weeks, Monday through Friday, 9:00 a.m.–5:30 p.m. Eastern (with corresponding regional schedules listed in the posting). The position is full-time, with 40 anticipated weekly hours. The stated starting rate is $18.50 per hour; the listed typical pay range is $17.00–$34.15 per hour.

Requirements

Less than one year of work experience.
Working knowledge of problem-solving and decision-making skills.
Experience in a production environment.
Claims-processing experience in any field.
High school diploma or equivalent.

Nice To Haves

Medicaid experience or knowledge.
QNXT experience or knowledge.
Medical coding experience or knowledge.
Microsoft Outlook and Excel skills.

Responsibilities

Handle and process benefit claims submitted by healthcare providers, ensuring accuracy, efficiency, and adherence to policies and guidelines.
Determine benefit eligibility and coverage based on the patient's insurance plan, policy guidelines, and scope.
Review claims for accuracy, coding compliance, medical necessity, and documentation requirements.
Document claim information in company systems and assign appropriate codes, modifiers, and other data elements.
Review and investigate claims requiring additional scrutiny or validation.
Communicate with healthcare providers, patients, and other stakeholders to resolve claim discrepancies or issues.
Ensure claims-processing activities comply with regulatory requirements, industry standards, and company policies.
Provide regular and formal performance feedback and support service delivery, engagement, motivation, and team development.
Analyze claims data and generate reports to identify trends, patterns, and opportunities for process, policy, or training improvements.
Review and adjudicate routine claims in accordance with claim-processing guidelines.
Analyze and approve routine claims that cannot be automatically adjudicated.
Apply medical-necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply cost-containment measures.
Coordinate responses to routine phone inquiries and written correspondence about claim-processing issues.
Route and triage complex claims to a Senior Claim Benefits Specialist.
Review claim or referral submissions and apply appropriate guidelines, coding, member-identification processes, diagnosis, and pre-coding requirements.
Facilitate training when considered a subject matter expert.
Manage claims, routing and queues, and ECHS within prescribed operational guidelines and turnaround-time parameters.
Use applicable system functions and tools to ensure accurate, timely claim processing, including claim checks, reasonable-and-customary data, and post-containment tools.