Claim Benefit Specialist Ops

Job Description
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).

Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.90

This 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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

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

jobs.CVSHealth.com/benefits

Required Qualifications
Experience in a production environment. High School or GED
Customer Focus
Attention to Detail
Strong Organizational Skills
Ability to work independently and as part of a team
Problem Solving

Preferred Qualifications
Banking background
Physicians office or hospital billing environment
Medical terminology

Education
High School or GED