Claim Benefit Specialist – Commercial Operations

CVS Health

. Handle and process Benefits claims submitted by healthcare providers .

Posted 9/21/2026full-timeRemote • United StatesJunior💰 $17 - $28 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims processing, eligibility determination, and compliance with regulatory requirements while effectively communicating with healthcare providers and stakeholders. Proficient in analyzing claims data and managing multiple assignments in a fast-paced environment.

Highest-signal resume keywords

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationEligibility DeterminationCoding ComplianceData AnalysisDocumentation RequirementsCost Containment MeasuresMedical Necessity GuidelinesRework Claims ProcessingSystem Functions UtilizationOperational Guidelines Management

Soft Skills

Strong CommunicationTeamworkOrganizational SkillsTime ManagementProblem-Solving

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

HealthcareInsurance PlansRegulatory ComplianceProduction EnvironmentClaims Data Trends

About the role

Key responsibilities & impact

Handle and process Benefits claims submitted by healthcare providers
Determine 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 elements in company systems
Conduct reviews and investigations 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
Provide feedback and participate in formal performance reviews to support service delivery and team development
Analyze claims data and generate reports identifying trends 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 claims or referrals and apply coding, member identification, provider selection, and pre-coding 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
Complete 12–20 weeks of virtual training from 8:00–4:30 EST

Requirements

What you’ll need

1–2 years experience working in Customer Service
Strong teamwork and organizational skills
Strong and effective communication skills
Ability to handle multiple assignments competently through use of 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)

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