Claim Benefit Specialist – Commercial Operations

CVS Health

. Handle and process benefits claims submitted by healthcare providers .

Posted 9/21/2026full-timeRemote • Tennessee • United StatesJunior💰 $17 - $26 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in claims processing, including assessing accuracy, medical necessity, and coding compliance. Proficient in analyzing claims data and ensuring compliance with regulatory requirements and industry standards.

Highest-signal resume keywords

Claims Processing ExperienceMedical Terminology KnowledgeEffective Communication SkillsTime Management AbilitiesTeamwork and Organizational Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationCoding ComplianceData AnalysisEligibility VerificationCost Containment Measures

Soft Skills

Strong CommunicationTeam CollaborationOrganizational SkillsTime ManagementProblem-Solving

Tools & Technologies

Claims Processing SystemsData Reporting Tools

Industry Keywords

Healthcare ClaimsRegulatory ComplianceInsurance PlansMedical Necessity GuidelinesProduction Environment

About the role

Key responsibilities & impact

Handle and process benefits claims submitted by healthcare providers
Determine benefits eligibility and coverage based on insurance plans and policy guidelines
Assess claims for accuracy, medical necessity, coding compliance, and documentation requirements
Document claim information and assign appropriate codes, modifiers, and data elements
Conduct reviews and investigations requiring additional scrutiny or validation
Communicate with healthcare providers, patients, and stakeholders to resolve claim discrepancies
Ensure claims processing complies with regulatory requirements, industry standards, and company policies
Provide regular, timely feedback and participate in formal performance reviews and team development
Analyze claims data and generate reports identifying trends, patterns, and improvement areas
Review and adjudicate claims according to processing guidelines
Apply medical necessity guidelines, verify eligibility, identify discrepancies, and apply cost containment measures
Review referrals and submissions and apply coding, member identification, and provider selection processes
Analyze and process rework claims that cannot be auto-adjudicated
Manage route lists and queues according to operational guidelines
Use applicable system functions to ensure accurate and timely claim processing

Requirements

What you’ll need

1–2 years of experience working in Customer Service
Strong teamwork and organizational skills
Strong and effective communication skills
Ability to handle multiple assignments competently through time management, accurately and efficiently
High School diploma, GED or equivalent experience
Experience in a production environment (preferred)
Healthcare experience (preferred)
Knowledge of utilizing multiple systems at once to resolve complex issues (preferred)
Claim processing experience (preferred but not required)
Understanding of medical terminology (preferred)
Ability to complete 12–20 weeks of virtual training, 8:00–4:30 EST
Ability to work 40 hours per week

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
Virtual training for 12–20 weeks
Flex schedule available after successful ramp up