Claim Benefit Specialist- Franklin, TN.

CVS Health•Franklin, TN

2d•Onsite

About The Position

Fast, accurate claims payment is one of the ways we make a difference in people's lives. Claims professionals work directly with members, doctors and employer groups, providing a friendly and knowledgeable voice at the other end of the phone at times when it's most needed. Analyze and process routine claims that cannot be auto-adjudicated. Apply medical necessity and coverage guidelines to support accurate claim decisions. Verify member eligibility and identify discrepancies affecting claim processing. Utilize cost-containment measures and claim adjudication tools to ensure accurate outcomes. Respond to routine claim-related phone inquiries and written correspondence. Route complex claims and issues to senior team members for resolution. Review claims and referrals for compliance with applicable guidelines, coding requirements, and member/provider information. Validate procedure, diagnosis, and pre-coding requirements to support accurate claim processing. Manage assigned claims, queues, and correspondence within established turnaround time standards. Process electronic correspondence using designated claims systems and workflows. Utilize claims processing tools, including Claim Check, reasonable and customary data, and other post-containment resources. Maintain accuracy, quality, and productivity standards while meeting service-level expectations. Provide training and guidance to team members when serving as a subject matter expert.

Requirements

1+ years of experience working in a production environment.
1+ years demonstrated ability to use Microsoft Office applications (Outlook, Word, Excel) and learn new software systems with minimal supervision.
Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
Ability to review information, identify basic issues, and recommend solutions to support day-to-day operations.

Nice To Haves

2+ years of experience claim processing.
Understanding of medical terminology.
Strong knowledge of benefit plans, policies, and procedures.

Responsibilities

Analyze and process routine claims that cannot be auto-adjudicated.
Apply medical necessity and coverage guidelines to support accurate claim decisions.
Verify member eligibility and identify discrepancies affecting claim processing.
Utilize cost-containment measures and claim adjudication tools to ensure accurate outcomes.
Respond to routine claim-related phone inquiries and written correspondence.
Route complex claims and issues to senior team members for resolution.
Review claims and referrals for compliance with applicable guidelines, coding requirements, and member/provider information.
Validate procedure, diagnosis, and pre-coding requirements to support accurate claim processing.
Manage assigned claims, queues, and correspondence within established turnaround time standards.
Process electronic correspondence using designated claims systems and workflows.
Utilize claims processing tools, including Claim Check, reasonable and customary data, and other post-containment resources.
Maintain accuracy, quality, and productivity standards while meeting service-level expectations.
Provide training and guidance to team members when serving as a subject matter expert.