Claim Benefit Specialist- Franklin, TN.

CVS Health•Franklin, TN

3d•$17 - $28

About The Position

The Claim Benefit Specialist performs claim documentation reviews, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and supports accurate and timely claims processing. The role contributes to efficient handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. This position processes benefit claims submitted by healthcare providers, evaluates eligibility and coverage under insurance plans, and reviews claims for accuracy, medical necessity, coding compliance, and required documentation. It also investigates claims requiring additional scrutiny, resolves discrepancies with stakeholders, documents claim details in company systems, and supports regulatory and policy compliance. The role analyzes claims data and generates reports to identify trends and opportunities for process improvements, policy changes, or training needs. It also includes providing timely feedback and participating in formal performance reviews to support service quality and team development.

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 required.

Nice To Haves

At least 1 year of experience with medical claim processing.
At least 1 year of experience in a production environment.
Ability to handle multiple assignments competently, accurately, and efficiently.
Effective communication, organizational, and interpersonal 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.
Assess claims for accuracy and compliance with coding guidelines, 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.
Determine whether claims processing complies with regulatory requirements, industry standards, and company policies.
Develop and implement regular, timely feedback and formal performance reviews to support service delivery, engagement, motivation, and team development.
Analyze claims data and generate reports to identify trends, patterns, and improvement opportunities that inform process enhancements, policy changes, or training needs.