Claim Benefit Specialist Ops

Job DescriptionReviews and adjudicates routine Medicare claims on HRP system in accordance with claim processing guidelines. Claims adjudication results should meet/exceed production and quality standards in line with CMS and Aetna compliance and business requirements.Analyzes and approves routine claims that cannot be auto adjudicated. - Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process. - Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements. - May facilitate training when considered topic subject matter expert. - In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor). - Utilizes all applicable system functions available ensuring accurate and timely claim processingNote-Claim positions can be assigned to various claim workstreams in the Medicare Service Claim Operation.Pay RangeThe typical pay range for this role is:Minimum: 17.00Maximum: 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 QualificationsExperience in a production environmentDetailed and quality orientedAbility to research and work within several computer applications simultaneouslyMicrosoft OutlookPreferred QualificationsClaim processing experienceComputer Navigation ProficiencyProduction & Quality backgroundMicrosoft Office toolsEducationHigh School or GED equivalentBusiness OverviewBring your heart to CVS Health Every 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. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Created: 2025-10-04