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
40Time Type
Full timePay Range
The typical pay range for this role is:
$17.00 - $28.46This 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 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.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Job details are sourced from the employer's original posting.
Open job postingAbout the company
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come. Excellent benefits package, including 401k, tuition, licensure and certification reimbursement. We promote healthy & wellness lifestyles and offer specialty programs here at Aetna. We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence. Together we will empower people to live healthier lives. Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities. We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.