Claim Benefit Specialist

4062 Aetna Resources, LLC; North Carolina; Hybrid; USD 23,000 - 35,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a claims examiner to review and adjudicate medical insurance claims, applying medical necessity guidelines, determining coverage, and verifying eligibility. The role involves handling rework, routing desk queues, and using system tools to ensure accurate, timely processing.

The position demands 1–2 years in customer service, strong teamwork, and excellent communication. Anticipated weekly hours are 40, with a pay range of $17.00–$25.65 per hour and a comprehensive benefits

Qualifications

• 1-2 years experience working in Customer Service.
• Possess strong teamwork and organizational skills
• Strong and effective communication skills
• Ability to handle multiple assignments competently through use of time management, accurately and efficiently

Responsibilities

• Reviews and adjudicates claims in accordance with claim processing guidelines.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
• Review claims 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.
• Analyzes and approves rework claims that cannot be auto adjudicated.
• Utilizes all applicable system functions available ensuring accurate and timely claim processing service.

Skills

Customer service

Teamwork

Communication skills

Time management

Education

High School diploma, GED or equivalent

Job description

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

• Reviews and adjudicates claims in accordance with claim processing guidelines.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
• Review claims 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.
• Analyzes and approves rework claims that cannot be auto adjudicated.– 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).

Required Qualifications

• 1-2 years experience working in Customer Service.
• Possess strong teamwork and organizational skills
• Strong and effective communication skills
• Ability to handle multiple assignments competently through use of time management, accurately and efficiently

Preferred Qualifications

• Experience in a production environment.
• Healthcare experience.
• 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, GED or equivalent Experience.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range The typical pay range for this role is: $17.00 - $25.65 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.

We anticipate the application window for this opening will close on: 09/26/2026

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

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.