Claim Benefit Specialist Ops

CVS Health

Feb 6

Applications are closed

Job
Full-time
Entry & Junior Level
Customer Relations
Healthcare
Phoenix

Requirements

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.

Responsibilities

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.
Review claims 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.
Analyzes and processes rework claims that cannot be auto adjudicated.
In accordance with prescribed operational guidelines, manages route list/queues.
Utilizes all applicable system functions available ensuring accurate and timely claim processing service.

FAQs

What is the primary purpose of the Claim Benefit Specialist Ops position?

The primary purpose of the Claim Benefit Specialist Ops position is to perform claim documentation review, verify policy coverage, assess claim validity, communicate with healthcare providers and policyholders, and ensure accurate and timely claims processing.

What are the essential duties of a Claim Benefit Specialist Ops?

Essential duties include handling and processing benefit claims, determining eligibility and coverage, assessing claims for accuracy, documenting claim information, conducting review and investigation of claims, and communicating with stakeholders to resolve discrepancies.

What skills are required for this position?

Required skills include strong teamwork and organizational skills, effective communication skills, ability to manage multiple assignments, and strong proficiency in using computers with data entry experience.

Is healthcare experience preferred for this role?

Yes, healthcare experience is preferred for this role, along with knowledge of medical terminology and claims processing experience.

What is the typical pay range for this position?

The typical pay range for this role is $17.00 - $34.15 per hour, depending on various factors including experience and location.

What benefits does CVS Health offer to employees in this position?

CVS Health offers a full range of benefits, including medical, dental, and vision coverage, a 401(k) retirement savings plan, paid time off, short-term and long-term disability benefits, and numerous well-being programs.

What educational qualifications are required for the Claim Benefit Specialist Ops position?

A high school diploma, GED, or equivalent experience is required for this position.

What kind of environment does this role work in?

This role typically operates in a production environment focusing on the efficient processing of claims.

Will I be required to work with multiple systems?

Yes, the role requires knowledge of utilizing multiple systems simultaneously to resolve complex claims issues.

When does the application window for this position close?

The application window for this opening is anticipated to close on 03/05/2025.

CVS Health

Bringing our heart to every moment of your health.

Science & Healthcare

Industry

10,001+

Employees

1963

Founded Year

Mission & Purpose

CVS Health is a healthcare innovation company that operates retail pharmacies, manages pharmacy benefits, and provides health services through its MinuteClinic and HealthHUB locations. Their ultimate aim is to improve the quality of life for communities by making healthcare more accessible and affordable. CVS Health focuses on driving healthier outcomes and reducing healthcare costs, using its comprehensive range of services and products to support individuals on their health journey.