Senior Claims Benefit Specialist - Checkwork/Refund

CVS Health

19h • $19 - $42

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. Position Summary Review and complete provider solicited and unsolicited overpayment refunds and returned checks; research, resolve, and adjudicates complex, sensitive, and/or specialized medical claims in accordance with claim processing guidelines. Research and adjust SF claims in accordance with claim processing guideline. Collaborate and partner with key business functions to ensure accuracy in posting overpayment refunds, problem-solve, and reconcile discrepancies. Handle internal inquiries/requests and respond to providers. 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. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. Ensures all compliance requirements are satisfied and that all payments and/or refunds are made following company practices and procedures. Performs medical claim re-work calculations and adjustments across all dollars as necessary for unsolicited overpayment refunds. Follow through completion of medical claim overpayments, underpayments, and any other irregularities. Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals. Review and handle relevant claims data mining work assigned to the team that may result in adjustments. Perform adjustments medical claims on customer service platforms by using technical and claims processing expertise. May deliver overpayment refund training and/or serve as a mentor for less experienced team members. May provide job shadowing to lesser experience staff. Utilize all resource materials to manage job responsibilities.

Requirements

• 2+ years medical claim processing experience.
• 2+ experience in a production environment.
• 1+ years processing medical claims adjustments/rework.

Nice To Haves

• Experience reviewing and researching overpayment refunds.
• DG system claims processing experience.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communications, organizational, and interpersonal skills.
• Familiarity with overpayment recovery.

Responsibilities

• Review and complete provider solicited and unsolicited overpayment refunds and returned checks
• Research, resolve, and adjudicates complex, sensitive, and/or specialized medical claims in accordance with claim processing guidelines
• Research and adjust SF claims in accordance with claim processing guideline
• Collaborate and partner with key business functions to ensure accuracy in posting overpayment refunds, problem-solve, and reconcile discrepancies
• Handle internal inquiries/requests and respond to providers
• 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
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
• Ensures all compliance requirements are satisfied and that all payments and/or refunds are made following company practices and procedures
• Performs medical claim re-work calculations and adjustments across all dollars as necessary for unsolicited overpayment refunds
• Follow through completion of medical claim overpayments, underpayments, and any other irregularities
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals
• Review and handle relevant claims data mining work assigned to the team that may result in adjustments
• Perform adjustments medical claims on customer service platforms by using technical and claims processing expertise
• May deliver overpayment refund training and/or serve as a mentor for less experienced team members
• May provide job shadowing to lesser experience staff
• Utilize all resource materials to manage job responsibilities

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree