Claim Benefit Specialist- Franklin, TN.

CVS Health • Franklin, TN

1d

About The Position

The Claim Benefit Specialist reviews and processes medical benefit claims submitted by healthcare providers. The role verifies policy coverage and benefit eligibility, evaluates claims for accuracy, medical necessity, coding compliance, and required documentation, and records claim details in company systems to support accurate tracking and reimbursement. The specialist also investigates claims requiring additional review, communicates with providers, patients, and other stakeholders to resolve discrepancies, and ensures processing activities follow regulatory requirements, industry standards, and company policies.

The position analyzes claims data and generates reports to identify trends and improvement opportunities. It also includes providing regular and timely feedback and participating in formal performance reviews to support service quality, colleague engagement, motivation, and team development. This is a full-time position based in Franklin, Tennessee, with anticipated hours of 40 per week.

Requirements

• At least 1 year of work experience in a customer service environment.
• Working knowledge of problem-solving and decision-making skills.
• High school diploma or equivalent.

Nice To Haves

• At least 1 year of experience with medical claim processing.
• At least 1 year of experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communication, organizational, and interpersonal skills.

Responsibilities

• Process benefit claims submitted by healthcare providers accurately, efficiently, and in accordance with 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 to ensure proper resolution.
• 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, timely feedback and participate in formal performance reviews to support service delivery and team development.
• Analyze claims data and generate reports to identify trends, patterns, and opportunities for process improvement, policy changes, or training.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being, based on eligibility

What This Job Offers

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