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Senior Claim Benefit Specialist
CVS Health
Posted: 9/24/2026Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in healthcare claims management, including CPT, ICD-10, and HCPCS coding, while effectively collaborating with vendors and internal teams to ensure compliance with clinical and reimbursement policies. Proven ability to lead initiatives, mentor staff, and analyze performance metrics to enhance vendor partnerships and claims-edit strategies.
Highest-signal resume keywords
Certified Professional Coder (CPC)CPT CodingICD-10 CodingHCPCS CodingHealth Insurance Experience
About the role
Key responsibilities & impact- Collaborate with external vendors in healthcare claims or payment integrity, including implementation support, claim-edit validation, issue escalation and resolution, performance monitoring, and vendor relationship management
- Lead and support internal and external claims-edit strategies using coding standards and industry rules
- Maintain and develop prospective claim edits and vendor partnerships using CPT, ICD-10, and HCPCS coding
- Determine payment compliance with clinical and reimbursement policies
- Research CPT codes and clarify coding issues
- Identify opportunities with current vendor partnerships and explore new opportunities
- Coordinate, review, and recommend changes for the yearly opportunity analysis
- Review and respond to claim-edit appeals and rational requests
- Coordinate, support, and resolve vendor needs prospectively and retrospectively
- Troubleshoot system and claim-edit issues
- Test and verify new claim edits during maintenance and vendor implementation
- Lead the Edit Expansion Committee and routine vendor-partner maintenance and oversight meetings
- Serve as a subject matter expert for internal workgroups and committees
- Clarify documentation and billing issues with providers and Account Managers
- Lead internal development, testing, maintenance, and expansion of claims edits
- Lead development of the ClaimsXten Policy Management Module
- Mentor less experienced staff and new hires
- Compile and coordinate routine performance reporting for vendor initiatives and support report-out meetings
Requirements
What you’ll need- Eastern United States resident
- High School Diploma or Equivalent (GED) (Required)
- Certified Professional Coder (CPC) with AAPC or Certified Coding Specialist with AHIMA certification (minimum one certification required)
- Minimum of 5 years related work experience (Required)
- Minimum of 5 years health insurance/managed care experience (Preferred)
- Knowledge of CPT, ICD-10, and HCPCS coding
- Knowledge of national correct coding standards, industry-standard coding rules, clinical policies, and reimbursement policies
- Certified Coding Specialist certification from AHIMA or Certified Professional Coder certification from AAPC
- Ability to collaborate with management, physicians, clinical and non-clinical personnel, providers, account managers, and external vendors
Benefits
Comp & perks- Healthcare benefits for full-time and part-time positions from day one
- Vision coverage
- Dental coverage
- Domestic partner benefits
- Collaborative, cooperative, and collegial work atmosphere
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 ManagementCoding StandardsPayment ComplianceClaims-Edit ValidationPerformance MonitoringIssue ResolutionVendor Relationship ManagementDocumentation ClarificationClaims-Edit AppealsOpportunity Analysis
Soft Skills
CollaborationMentoringCommunicationProblem-SolvingLeadership
Tools & Technologies
ClaimsXten Policy Management Module
Certifications & Qualifications
Certified Professional Coder (CPC)Certified Coding Specialist (CCS)
Industry Keywords
Healthcare ClaimsPayment IntegrityNational Correct Coding StandardsReimbursement PoliciesManaged Care