Claim Processing Specialist Jobs (NOW HIRING)

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Position Summary
Manages day-to-day activities of team by providing strategic leadership and overseeing the operations of the claims processing team(s). Directs work flow to ensure the efficient and accurate processing of medical claims by establishing and monitoring productivity and quality metrics, managing and developing a team of claims support individuals, implementing process improvement initiatives, and fostering collaboration with internal and external stakeholders to optimize claim processing, minimize errors, and enhance overall operational effectiveness and customer satisfaction.

What you will do

• Reviews claims for completeness, accuracy, and adherence to company policies and procedures, addressing any complex or escalated claims issues to provide guidance to claim processors in handling challenging cases.
• Designs quality control processes to ensure the accuracy and consistency of claim processing, including critical follow-up procedures for effective final resolution.
• Assists with the development of the claim processing budget by monitoring expenses, tracking budget variances, and identifying cost-saving opportunities while maintaining operational effectiveness and service quality.
• Analyzes claim processing data and generates reports to track and evaluate key performance metrics, such as claim volume, turnaround time, accuracy rates, and productivity.
• Collaborates with other departments, such as underwriting, legal, or customer service, to ensure effective communication and coordination in the claim processing workflow.
• Encourages feedback from claim processors, gathers suggestions for process enhancements, and implements changes that improve efficiency, accuracy, and customer satisfaction.
• Ensures compliance with industry regulations, company policies, and legal requirements related to claim processing and implements necessary adjustments to processes, documentation, or reporting requirements to maintain compliance.
• Oversees ongoing training to ensure all team members are fully versed and compliant within their respective roles for claims handling and escalation.
• Coordinates with internal and external business partners to provide leadership, functional advice, and training to staff as needed.

Required Qualifications

• 5-7 years of experience in healthcare claims and/or operations.
• 5-7 years of demonstrated leadership experience, including team oversight and performance management.
• Demonstrates strong execution and delivery capabilities, including planning, implementation, and ongoing support.
• Demonstrates strong problemsolving and sound decisionmaking capabilities in complex environments.
• Proven ability to collaborate effectively across teams and build strong partnerships with diverse stakeholders.
• Exhibits a growth mindset, including adaptability, continuous learning, and the ability to develop self and others.
• Strong written and verbal communication skills.

Preferred Qualifications

• Certified Billing and Coding Specialist (CBCS) preferred.
• Candidates located on the East Coast preferred.

Education

• High school diploma and/or postsecondary education or specialized training (e.g., technical or vocational programs)

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

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.

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.