Claim Benefit Specialist- Commercial Operations

CVS Health•Work At Home-Tennessee, TN

3d•$17 - $26

About The Position

The Claim Benefit Specialist handles medical benefit claims submitted by healthcare providers, reviewing and adjudicating claims according to processing guidelines, policy terms, and regulatory requirements. The role verifies eligibility and coverage, assesses medical necessity, coding, and supporting documentation, records claim information accurately, and investigates claims requiring additional review. It also involves communicating with providers, patients, and other stakeholders to resolve claim discrepancies; analyzing claims data and reporting trends; and supporting process improvements, policy changes, and training needs. The position includes 12–20 weeks of virtual training, with the position summary specifying 20 weeks of virtual training. A flexible schedule is available after successful ramp-up. The specialist manages claim queues, processes claims that cannot be automatically adjudicated, and uses available systems to ensure accurate and timely service. The posting also describes providing timely feedback and participating in formal performance reviews to support service delivery and team development.

Requirements

1–2 years of experience working in customer service.
Strong teamwork and organizational skills.
Strong and effective communication skills.
Ability to manage multiple assignments competently using time management skills, accurately and efficiently.
High school diploma, GED, or equivalent.

Nice To Haves

Experience in a production environment.
Healthcare experience.
Knowledge of using multiple systems at once to resolve complex issues.
Claims processing experience; preferred but not required.
Understanding of medical terminology.

Responsibilities

Handle and process benefits claims submitted by healthcare providers accurately, efficiently, and in accordance with policies and guidelines.
Determine benefit eligibility and coverage based on insurance plans, policy guidelines, and scope.
Review claims for accuracy, medical necessity, coding compliance, and required documentation.
Document claim information in company systems, including 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 complies with regulatory requirements, industry standards, and company policies.
Develop and provide timely feedback and participate in formal performance reviews to support service quality, engagement, motivation, and team development.
Analyze claims data and generate reports to identify trends and opportunities for process improvements, policy changes, or training.
Review and adjudicate claims in accordance with claim processing guidelines.
Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and apply cost-containment measures.
Review claims or referral submissions and apply applicable guidelines, coding, member identification, provider selection, and pre-coding requirements.
Analyze and process rework claims that cannot be automatically adjudicated.
Manage route lists and queues according to operational guidelines.
Use applicable system functions to ensure accurate and timely claims processing.