Claim Benefit Specialist

Job DescriptionReviews and adjudicates routine claims in accordance withclaim processing guidelines.Pay RangeThe typical pay range for this role is:Minimum: 17.02Maximum: 27.16Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required Qualifications- Looking for English, Japanese, and Spanish speaking individuals for this Claims Benefits role. - Analyzes and approves routine claims that cannot beauto adjudicated.- Applies medical necessity guidelines, determinecoverage, complete eligibility verification, identifydiscrepancies, and applies all cost containment measures to assist in the claim adjudication process.- Coordinates responses for routine phone inquiries andwritten correspondence related to claim processing issues.- Routes and triages complex claims to Senior ClaimBenefits Specialist.- Proofs claim or referral submission to determine, review,or apply appropriate guidelines, coding, memberidentification processes, provider selection processes,claim coding, including procedure, diagnosis andprecoding requirements.- May facilitate training when considered topic subjectmatter expert.- In accordance with prescribed operational guidelines,manages claims on desk, route/queues, and ECHS withinspecified turn-around-time parameters (ElectronicCorrespondence Handling System-system used toprocess correspondence that is scanned in the system bya vendor).- Utilizes all applicable system functions available ensuringaccurate and timely claim processing service (i.e., utilizesClaim Check, reasonable and customary data, and otherpost-containment tools)COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications- Experience in a production environment.- MUST have knowledge of utilizing multiple systems atonce to resolve complex issues.- Claim processing experience preferred but not required.-Must understand medical terminologyEducationHigh School or GED equivalent.Business OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-09-06