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).
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.