Provider Data Services Specialist - Claim Pends

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.

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.

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  Research and resolve provider-related claim pends using internal systems (e.g., claims and provider modules).

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  Analyze pend root causes related to provider enrollment, contracting, affiliations, specialties, pay-to relationships, and configuration issues.

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  Update provider records and/or route claims appropriately to allow claims to continue through adjudication.

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  Apply state-specific Medicaid requirements and business rules when resolving claims.

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  Document actions clearly and accurately in claim memos and tracking tools.

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  Manage assigned inventory daily, prioritizing aged and high-impact claims to meet established TAT and productivity standards.

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  Identify trends in pended claims and escalate systemic issues to leadership or appropriate partners.

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  Collaborate with Provider Data, Claims, Quality, Automation (BOT), and Implementation teams to improve workflows and reduce repeat pends.

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  Support audit and quality review activities by providing documentation and responding to findings.

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  Follow established procedures, job aids, and compliance standards.

• 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.

• 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.

• High school diploma or equivalent required

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. 
 

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