Claim Benefit Specialist, CVS Health

CVS Health

Location:
United States, Work At Home, North Carolina

Category:
Customer Service

Contract Type:
Employment contract

Salary:

17.00 - 25.65 USD / Hour

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Job Description:

Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills.

Job Responsibility:

Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines
Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope
Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements
Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims
Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution
Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims
Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies
Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development
Analyzes claims data and generate reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department

Requirements:

1-2 years’ experience working in Customer Service
Possess strong teamwork and organizational skills
Strong and effective communication skills
Ability to handle multiple assignments competently through use of time management, accurately and efficiently
Strong proficiency using computers and experience with data entry

Nice to have:

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

What we offer:

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
May 01, 2025

Expiration:
May 09, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Claim Benefit Specialist