Claims benefit specialist job description
Updated March 14, 2024
6 min read
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Example claims benefit specialist requirements on a job description
Claims benefit specialist requirements can be divided into technical requirements and required soft skills. The lists below show the most common requirements included in claims benefit specialist job postings.
Sample claims benefit specialist requirements
- Bachelor's degree in a related field
- Experience in claims processing and benefit administration
- Knowledge of state and federal regulations related to benefit programs
- Proficient in Microsoft Office Suite and database management
- Ability to analyze and interpret complex data
Sample required claims benefit specialist soft skills
- Excellent communication and interpersonal skills
- Ability to work independently and in a team environment
- Strong organizational and time management skills
- Attention to detail and accuracy
- Customer service oriented mindset
Claims benefit specialist job description example 1
CVS Health claims benefit specialist job description
Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems.
Pay Range
The typical pay range for this role is:
Minimum: 18.50
Maximum: 33.65
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
- Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment. measures to assist in the claim adjudication process.- Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.- Insures all compliance requirements are satisfied and all payments are made against company practices and procedures.- Identifies and reports possible claim overpayments, underpayments and any other irregularities. - Performs claim rework calculations. - Distributes work assignment daily to junior staff.- Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration.
COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
Preferred Qualifications
- 2+ years claim processing experience. - Experience in a production environment.- Claim processing experience.- Demonstrated ability to handle multiple assignments competently, accurately and efficiently
Education
- Associates degree or equivalent work experience.
Business Overview
Bring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
Pay Range
The typical pay range for this role is:
Minimum: 18.50
Maximum: 33.65
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
- Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment. measures to assist in the claim adjudication process.- Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.- Insures all compliance requirements are satisfied and all payments are made against company practices and procedures.- Identifies and reports possible claim overpayments, underpayments and any other irregularities. - Performs claim rework calculations. - Distributes work assignment daily to junior staff.- Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration.
COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
Preferred Qualifications
- 2+ years claim processing experience. - Experience in a production environment.- Claim processing experience.- Demonstrated ability to handle multiple assignments competently, accurately and efficiently
Education
- Associates degree or equivalent work experience.
Business Overview
Bring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
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Claims benefit specialist job description example 2
Aetna claims benefit specialist job description
* Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.
* Acts as a subject matter expert by providing training, coaching, or responding to complex issues
* Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise
* Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
* Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures
* Identifies and reports possible claim over payments, underpayments and any other irregularities
* Performs claim re-work calculations
* Distributes work assignments daily to junior staff
* Trains and mentors claim benefit specialists
* Makes outbound calls to obtain required information for First claim or re-consideration
* Works with Health Plan Operations and within the State Encounter system to research and resolve errors
Pay Range
The typical pay range for this role is:
Minimum: 18.50
Maximum: 33.65
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
* Experience in a production environment
* Demonstrated ability to handle multiple assignments competently, accurately and efficiently
* 2+ years Medical Claim processing experience
COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
Preferred Qualifications
Experience in updating or developing standard operating procedures when new edits presented
Medicaid experience preferred
Education
Associate's degree or equivalent work experience
Business Overview
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
* Acts as a subject matter expert by providing training, coaching, or responding to complex issues
* Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise
* Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
* Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures
* Identifies and reports possible claim over payments, underpayments and any other irregularities
* Performs claim re-work calculations
* Distributes work assignments daily to junior staff
* Trains and mentors claim benefit specialists
* Makes outbound calls to obtain required information for First claim or re-consideration
* Works with Health Plan Operations and within the State Encounter system to research and resolve errors
Pay Range
The typical pay range for this role is:
Minimum: 18.50
Maximum: 33.65
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
* Experience in a production environment
* Demonstrated ability to handle multiple assignments competently, accurately and efficiently
* 2+ years Medical Claim processing experience
COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
Preferred Qualifications
Experience in updating or developing standard operating procedures when new edits presented
Medicaid experience preferred
Education
Associate's degree or equivalent work experience
Business Overview
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
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Updated March 14, 2024
Updated March 14, 2024