Claim Benefit Specialist

Employer: CVS Health

Job Description

This is a Claim Benefit Specialist work from home opportunity for candidates mainly in the CST and PST time zones.

• 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, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
• 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 processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.

Required Qualifications:

• Analyzes and approves routine claims that cannot be auto adjudicated.
• Applies medical necessity guidelines, determine coverage, complete eligibility 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 processes, provider selection processes, claim coding, including procedure, diagnosis and precoding 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 service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).

COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.

• If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
• If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications:

• Experience in a production environment.
• Knowledge of utilizing multiple systems at once to resolve complex issues.
• Claim processing experience preferred but not required.
• Understanding of medical terminology

Education:

• High School Diploma or GED equivalent.

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