Claim Benefit Specialist

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 processing

Note: Our CBS positions in Medicare are not limited to Front-End Claims. These positions can support various Medicare workstreams as determined by business need. This can be either FE Claims, Specialty work or our Rework team.-

Required Qualifications
Experience in a production environment
Detailed and quality oriented
Ability to research and work within several computer applications simultaneously
Microsoft Outlook

Preferred Qualifications
Claim processing experience
Computer Navigation Proficiency
Production & Quality background
Microsoft Office tools

Education
High School or GED equivalent Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$17.00 - $28.46This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will close on: 05/23/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.