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).

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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