Claim Benefit Specialist (Must live and work the Eastern or Central Time Zone)

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Must live in and work the Eastern or Central Time Zone

Position Summary

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, complete eligibly 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 process, diagnosis and pre-coding 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 services (i.e. utilizes claim check, reasonable and customary data, and other post-containment tools).

Required Qualifications

• Experience in a production environment.

• Claims processing experience in any field. 

Preferred Qualifications

• Medicaid
• QNXT
• Medical Coding

Education

High School diploma or GED equivalent

Anticipated Weekly Hours

40

Time Type

Full time

The hours listed below are the required availability for this role. Please only apply if you can meet these schedule requirements.

Shift Flexibility:

Monday: -

Tuesday: -

Wednesday: -

Thursday: -

Friday: -

Saturday: -

Sunday: -

Weekend Shift Frequency:

Language

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. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

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. 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 08/12/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.