Senior Claims Benefit Specialist - Checkwork/Refund

CVS Health

2d•Onsite

About The Position

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.

Requirements

3+ years of medical claims processing experience
2+ years of hands-on claim adjustments/rework experience
2+ years in a production environment (volume + accuracy expectations)
Demonstrated experience researching and resolving claim issues end-to-end
Ability to interpret and apply guidelines related to eligibility, coverage, and benefits
High attention to detail

Nice To Haves

Experience reviewing and researching overpayment refunds
DG system claims processing experience
Ability to manage multiple assignments accurately and efficiently
Effective communication, organizational, and interpersonal skills
Familiarity with overpayment recovery

Responsibilities

Review and complete provider-solicited and unsolicited overpayment refunds and returned checks.
Research, resolve, and adjudicate complex, sensitive, and/or specialized medical claims in accordance with claims-processing guidelines.
Partner with key business functions, ensure accurate posting of overpayment refunds, reconcile discrepancies, and respond to internal and provider inquiries.
Process complex, non-routine provider refunds and returned checks.
Review and interpret contract language to validate overpayments and allocate refund checks appropriately.
Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply cost-containment measures to support claim adjudication.
Ensure compliance requirements are met and that payments/refunds follow company practices and procedures.
Perform claim rework calculations and adjustments across all dollar amounts for unsolicited overpayment refunds.
Follow through to completion on medical claim overpayments, underpayments, and other irregularities.
Respond to telephone and/or written inquiries related to pre-approvals/pre-authorizations, reconsiderations, and appeals.
Review assigned claims data mining work that may result in claim adjustments and complete resulting adjustments as appropriate.
Process medical claim adjustments on customer service platforms using technical and claims-processing expertise.
Provide overpayment refund training, mentoring, and job shadowing support for less experienced colleagues, as assigned.
Use available resource materials and tools to manage job responsibilities.
Handle customer service inquiries and issues assigned.