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.

This is a hybrid role requiring reporting to the Franklin, TN Aetna office three days a week with no exceptions.

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.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.