[Hiring] Provider Data Services Specialist @CVS Health

Role Description

The Provider Data Services Specialist for the PDS Claim Pend team is responsible for researching, analyzing, and resolving provider-related claim pends to ensure timely and accurate claims adjudication. This role focuses on resolving pended claims caused by provider data, contract, affiliation, or configuration of issues within claims and provider systems. The analyst partners closely with internal Provider Data, Claims, Quality, and Implementation teams to reduce inventory aging, meet turnaround time (TAT) requirements, and maintain compliance with state Medicaid guidelines.

• Research and resolve provider-related claim pends using internal systems (e.g., claims and provider modules).
• Analyze pend root causes related to provider enrollment, contracting, affiliations, specialties, pay-to relationships, and configuration issues.
• Update provider records and/or route claims appropriately to allow claims to continue through adjudication.
• Apply state-specific Medicaid requirements and business rules when resolving claims.
• Document actions clearly and accurately in claim memos and tracking tools.
• Manage assigned inventory daily, prioritizing aged and high-impact claims to meet established TAT and productivity standards.
• Identify trends in pended claims and escalate systemic issues to leadership or appropriate partners.
• Collaborate with Provider Data, Claims, Quality, Automation (BOT), and Implementation teams to improve workflows and reduce repeat pends.
• Support audit and quality review activities by providing documentation and responding to findings.
• Follow established procedures, job aids, and compliance standards.

Qualifications

• 2–3 years of experience in healthcare operations, claims processing, provider data maintenance, or related roles.
• Strong analytical and problem-solving skills with attention to detail.
• Ability to interpret policies, procedures, and state-specific Medicaid requirements.
• Proficiency in navigating multiple systems and tools simultaneously.
• Strong written communication skills for documentation and claim memo entry.
• Ability to manage workload independently in a production-driven environment.

Requirements

• Experience working claim pends, provider data, enrollment, or contracting issues preferred.
• Experience supporting Medicaid or government programs.
• Familiarity with provider data systems, claims platforms, or healthcare configuration tools.
• Experience working with production metrics, quality audits, or compliance standards.
• Prior experience identifying trends or contributing to process improvements.

Education

• High school diploma or equivalent required.

Benefits

• Comprehensive and competitive mix of pay and benefits.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.