Claim Field Specialist (South Florida)

CVS Health•Fort Myers, FL

7d•$46,988 - $102,000•Hybrid

About The Position

The Claim Field Specialist serves as the primary resource for groups and providers in an assigned geographic area, establishing and maintaining a proactive claims education program. The role helps providers address claim denials, understand claims requirements, and resolve claims issues. It analyzes denial trends and identifies opportunities for provider training, while developing educational materials such as bulletins, newsletters, and training sessions. The specialist collaborates with internal and external teams to promote provider training strategies and improve provider satisfaction with claim submission and payment processes. The specialist works with the grievance and appeal department to identify provider disputes and appeals that could be prevented through education, and partners with the provider engagement team when additional detailed education is needed. Regular meetings with assigned providers—both in person and virtually—cover training, claim trends, and Aetna Medicaid claim and billing policies and procedures. The position is expected to spend 70% of its time meeting with providers in person, with occasional phone or virtual meetings. It also responds to provider claim inquiries and coordinates with appropriate enterprise teams to resolve issues. The role is based in Central Florida, with residence in the specified Tampa and/or Orlando regions, and requires travel within Central Florida. The remaining work time is remote. The stated schedule is Monday through Friday, 8 a.m. to 5 p.m. Eastern, with flexibility to work beyond core hours as needed.

Requirements

At least 2 years of experience in medical billing and coding, specifically related to claims processing and root cause analysis.
At least 2 years of experience with provider engagement and/or relations.
Working proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.
Advanced Microsoft Excel experience for data mining.
Must reside in Central Florida: Tampa Region D (Hardee, Highlands, Hillsborough, Manatee, Polk) and/or Orlando Region E (Brevard, Orange, Osceola, Seminole).
Willingness to travel 70% of the time within Central Florida and work remotely the remaining 30%.
Willingness to work Monday through Friday, 8 a.m. to 5 p.m. Eastern, with flexibility to work beyond core hours as needed.
High school diploma or GED.

Nice To Haves

Excellent verbal and written communication skills.
Regular and reliable attendance.
Associate’s or bachelor’s degree.
Certified Professional Coder (CPC) certification.

Responsibilities

Establish, oversee, and maintain a proactive claims education program for groups and providers in an assigned geographic area.
Assist providers with claim denials, claim education, and claim resolution.
Analyze claim denials to identify and track trends and opportunities for provider training and education.
Create bulletins, newsletters, and claims training to address provider claims issues and improve billing practices.
Collaborate with internal and external departments to identify claims training and education opportunities.
Develop, implement, support, and promote provider training strategies, tactics, policies, and programs related to claim submission and payments.
Work with the grievance and appeal department to identify provider claim disputes and appeals that may be prevented through education.
Partner with the provider engagement team when providers need additional detailed claims education.
Meet with assigned providers in person and virtually to conduct training, review claim trends, and explain Aetna Medicaid claim and billing policies and procedures.
Respond to assigned provider claim questions and inquiries and coordinate prompt resolution with appropriate enterprise business teams when necessary.
Perform other duties as assigned.