Senior Claims Benefit Specialist - Checkwork/Refund

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.

Required Qualifications

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

Preferred Qualifications

• 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.

Education

• Associate degree or equivalent experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$18.50 - $42.35

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• 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 incl