Claim Benefit Specialist- Franklin, TN.

4062 Aetna Resources, LLC; Franklin (VA); On-site; USD 35,000 - 59,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Paid time off

Retirement options

Job summary

CVS Health is seeking a claims processor to support fast, accurate payments and member interactions. You will analyze routine claims not auto-adjudicated, apply coverage guidelines, verify eligibility, and route complex items to senior staff for resolution.

You will maintain accuracy, respond to inquiries, and provide guidance to teammates as needed, ensuring adherence to service-level targets and quality standards.

Qualifications

• 1+ years of experience in a production environment.
• Proficiency with Microsoft Office applications (Outlook, Word, Excel) and ability to learn new software.
• Ability to handle multiple assignments competently, accurately, and efficiently.

Responsibilities

• Analyze and process routine claims that cannot be auto-adjudicated.
• Apply medical necessity and coverage guidelines to support accurate claim decisions.
• Verify member eligibility and identify discrepancies affecting claim processing.
• Route complex claims and issues to senior team members for resolution.
• Maintain accuracy and productivity standards while meeting service-level expectations.

Skills

Production experience

MS Office

Multitasking

Analytical thinking

Education

High School or GED

Tools

Claim Check

Claims processing software

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

Fast, accurate claims payment is one of the ways we make a difference in people's lives. Claims professionals work directly with members, doctors and employer groups, providing a friendly and knowledgeable voice at the other end of the phone at times when it's most needed. Analyze and process routine claims that cannot be auto-adjudicated. Apply medical necessity and coverage guidelines to support accurate claim decisions. Verify member eligibility and identify discrepancies affecting claim processing. Utilize cost-containment measures and claim adjudication tools to ensure accurate outcomes. Respond to routine claim-related phone inquiries and written correspondence. Route complex claims and issues to senior team members for resolution. Review claims and referrals for compliance with applicable guidelines, coding requirements, and member/provider information. Validate procedure, diagnosis, and pre-coding requirements to support accurate claim processing. Manage assigned claims, queues, and correspondence within established turnaround time standards. Process electronic correspondence using designated claims systems and workflows. Utilize claims processing tools, including Claim Check, reasonable and customary data, and other post-containment resources. Maintain accuracy, quality, and productivity standards while meeting service-level expectations. Provide training and guidance to team members when serving as a subject matter expert.

Required Qualifications

• 1+ years of experience working in a production environment.
• 1+ years demonstrated ability to use Microsoft Office applications (Outlook, Word, Excel) and learn new software systems with minimal supervision.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Ability to review information, identify basic issues, and recommend solutions to support day-to-day operations.

Preferred Qualifications

• 2+ years of experience claim processing.
• Understanding of medical terminology.
• Strong knowledge of benefit plans, policies, and procedures.

Education

• High School or GED equivalent.

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.

Benefits

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: 09/30/2026

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

Company culture

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.