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Claim Benefit Specialist
CVS Health. Handle and process benefits claims submitted by healthcare providers .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims processing, including eligibility determination, coding compliance, and adherence to regulatory requirements. Proficient in analyzing claims data and communicating effectively with healthcare providers and stakeholders.
Highest-signal resume keywords
Claims Processing ExperienceMedical CodingQNXTMicrosoft OutlookMicrosoft Excel
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AdjudicationCoding ComplianceMedical Necessity GuidelinesData AnalysisDocumentation Requirements
Soft Skills
Problem SolvingDecision MakingCommunication
Tools & Technologies
Claim CheckECHSPost-Containment Tools
Industry Keywords
MedicaidHealthcare ProvidersInsurance PlansRegulatory ComplianceProduction Environment
About the role
Key responsibilities & impact- Handle and process benefits claims submitted by healthcare providers
- Determine benefit eligibility and coverage based on insurance plans and policy guidelines
- Assess claims for accuracy, coding compliance, medical necessity, and documentation requirements
- Document claim information, codes, modifiers, and other data in company systems
- Review and investigate claims requiring additional scrutiny or validation
- Communicate with healthcare providers, patients, and stakeholders to resolve discrepancies
- Ensure claims processing complies with regulatory requirements, industry standards, and company policies
- Review and adjudicate routine claims according to processing guidelines
- Analyze and approve routine claims that cannot be auto-adjudicated
- Apply medical necessity guidelines, verify eligibility, identify discrepancies, and apply cost-containment measures
- Coordinate responses to routine phone inquiries and written correspondence
- Route and triage complex claims to the Senior Claim Benefits Specialist
- Proof claim or referral submissions and apply appropriate guidelines, coding, member identification, diagnosis, and pre-coding requirements
- Facilitate training when serving as a subject matter expert
- Manage claims, queues, and ECHS within specified turnaround-time parameters
- Use applicable system functions, including claim check, reasonable and customary data, and post-containment tools
- Develop and implement feedback and performance review processes
- Analyze claims data and generate reports to identify trends and improvement opportunities
Requirements
What you’ll need- Less than 1 year work experience
- Working knowledge of problem solving and decision making skills
- High school diploma or equivalent required
- Experience in a production environment
- Claims processing experience in any field
- Preferred: Medicaid
- Preferred: QNXT
- Preferred: Medical Coding
- Preferred: Microsoft Outlook/Excel
- Ability to adhere to a 20-week training schedule
- Ability to work Monday through Friday, 9AM–5:30PM EST (8AM–4:30PM CST, 7AM–3:30PM MST, 6AM–2:30PM PST)
Benefits
Comp & perks- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility