Claim Benefit Specialist

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. A Brief Overview Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. What you will do Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements. Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution. Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.</sp

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. A Brief Overview Performs claim documentation review, verifies policy coverage, assesses claim validity, communicates with healthcare providers and policyholders, and ensures accurate and timely claims processing. Contributes to the efficient and accurate handling of medical claims for reimbursement through knowledge of medical coding and billing practices and effective communication skills. What you will do Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines. Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope. Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements. Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims. Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution. Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.</sp

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 complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines. Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues. Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience. Additional Responsibilities - Reviews pre‑specified claims and those that exceed specialist adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost‑containment measures to support accurate claim adjudication. - Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures. - Identifies and reports potential overpayments, underpayments, and other claim irregularities. - Performs claim rework calculations as needed. - Trains and mentors as needed to enhance team performance and technical proficiency. - Conducts outbound calls to obtain required information for claims or reconsideration requests. Required Qualifications - Minimum of 18 months of medical claim processing experience with a health insurance payor or third‑party administrator. - Proven

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 Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Process provider refunds and returned checks. May handle customer service inquiries and problems. Perform adjustments across all dollar amount level on customer service platforms by using technical and claims 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. Performs claim re-work calculations. Follow through completion of claim overpayments, underpayments, and any other irregularities. Process complex non-routine Provider Refunds and Returned Checks. Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks. Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals. Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures. Review and handle relevant correspondences assigned to the team that may result in adj

Job Title: Junior Revenue Cycle Management (RCM) Specialist Location: Remote - United States Employment Type: FT W2 Compensation: $35 per hour CareTalk Health is a virtual medical practice that specializes in Clinical Process Outsourcing (CPO). We partner with healthcare organizations to build and manage patient and member populations. About the Role We’re looking for a Junior RCM Specialist to support the full revenue cycle — from billing and credentialing through claims processing, payment posting, and accounts receivable follow-up. This is an ideal role for someone early in their medical billing or healthcare administration career who has a solid grasp of the insurance workflow and wants to grow in a fast-paced virtual care environment. The ideal candidate understands how claims move through the insurance lifecycle, has exposure to provider credentialing, and is comfortable managing accounts receivable. You’re organized, analytical, proactive, and at ease working across billing systems, payer portals, and cross-functional teams. Schedule: Monday - Friday Days What You’ll Do • Support claim submission to ensure timely, accurate billing • Monitor claim status and follow up on unpaid or denied claims • Assist with provider credentialing and payer enrollment, keeping documentation and records current • Manage accounts receivable, including aging follow-up, collections, and resolution of outstanding balances • Support denial management by identifying issues, documenting trends, and escalating complex cases • Post payments, adjustments, and remittance information accurately • Reconcile billing discrepancies and resolve account issues • Verify patient eligibility, insurance information, and benefits as part of the insurance workflow • Maintain documentation of billing activity, follow-up efforts, and account status • Communicate with payers, vendors, and internal teams on claim issues and payment delays • Help track key R

About the Team OpenAI’s mission is to ensure that general-purpose artificial intelligence benefits all of humanity. We believe that achieving our goal requires effective engagement with public policy stakeholders and the broader community impacted by AI. Accordingly, our Global Affairs team builds authentic, collaborative relationships with public officials and the broader AI policymaking community to inform and support our shared work in these domains. We ensure that insights from policymakers inform our work and – in collaboration with our colleagues and external stakeholders – seek to shape policy so that it aligns with and supports our mission. About the Role As AI agents move from answering questions to taking action across the internet, the standards that govern identity, delegated authority, discovery, communications, agentic-commerce and payment interfaces, agent-facing web access, agent-specific provenance, and auditability will determine whether agents can operate safely, interoperably, and with clear accountability. OpenAI is looking for an Agent Standards Manager to lead execution of our external technical standards strategy for a defined set of agent standards workstreams. This role will work closely with Agent Security, Applied and Platform teams, Product, Legal, GRC, Global Affairs, and GTM to turn OpenAI’s technical architecture and controls into credible specifications, protocol profiles, assurance criteria, and implementation guidance—and to bring emerging external requirements back into product and security roadmaps before they become blockers. The positions developed here are technical standards positions, not broad public-policy positions. This is a builder’s role as much as an external-facing role. You will execute a prioritized standards plan, author and negotiate protocols, build coalitions, secure the right internal approvals, and represent OpenAI in assigned technical forums. You will also help create repeatable processes that let the compa