Claim Benefit Specialist Operations

Claims Processing Specialist

We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary: A Brief Overview

Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills.

What You Will Do:

• Handles and processes benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines.
• Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope.
• Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements.
• Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims.
• Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution.
• Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.
• Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies.
• Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.
• Analyzes claims data and generate reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.

Required Qualifications:

• Less than one (1) year of relevant experience in healthcare, insurance, claims processing, billing, coding, customer service, or administrative support.
• Ability to read, interpret, and apply policies, procedures, and benefit plan information.
• Strong attention to detail and accuracy when reviewing data, documentation, and codes.
• Basic proficiency with computer systems and data entry, including the ability to learn claims processing systems and software.
• Effective written and verbal communication skills, with the ability to communicate professionally with healthcare providers, policyholders, and internal teams.
• Ability to manage multiple tasks, meet deadlines, and work effectively in a fast‑paced, production‑oriented environment.
• Ability to work independently and collaboratively as part of a team.

Preferred Qualifications:

• Familiarity with medical billing, claims processing, or healthcare terminology.
• Experience working with highly confidential or regulated information.
• Prior experience in a healthcare, insurance, or customer service environment.
• Comfortable working in a hybrid work environment.
• Some experience in a highly regulated, fast pace environment.

Education:

High school diploma or equivalent required.

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: The typical pay range for this role is: $17.00 - $28.46

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.

Our People Fuel Our Future

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be.

Great Benefits for Great People

In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.