Claim Benefit Specialist OPS

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.Position Summary

Reviews and adjudicates routine claims in accordance with claim processing guidelines.

• Analyzes and approves routine claims that cannot be auto adjudicated.

• Applies medical necessity guidelines, determines coverage, complete eligibly verification, identify discrepancies and applies all cost containment measures to assist in the claim adjudication process.

• Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.

• Routes and triages complex claims to Senior Claim Benefits Specialist.

• Proofs claim or referral submission to determine, review or apply appropriate guidelines, coding, member identification process, diagnosis and pre-coding requirements.

• May facilitate training when considered topic subject matter expert.

• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic correspondence Handling System - system used to process correspondence that is scanned in the system by a vendor).

• Utilizes all applicable system functions available ensuring accurate and timely claim processing services (i.e. utilizes claim check, reasonable and customary data, and other post-containment tools).Required Qualifications

• Experience in a production environment.

• Claim processing experience.

• High School diploma or GED equivalent.Preferred Qualifications

• Medicaid
• QNXT
• Medical Coding

Education

High School diploma or GED equivalentPay Range

The typical pay range for this role is:$17.00 - $28.46This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS HealthWe anticipate the application window for this opening will close on: 02/17/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.