[Hiring] Senior Claim Benefit Specialist @CVS Health

Role Description

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 to ensure accurate posting of overpayment refunds, reconcile discrepancies, and respond to internal and provider inquiries.

Key Responsibilities

• 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 implement cost-containment measures to support claim adjudication.
• Ensure compliance requirements are met and that payments and refunds follow company policies and procedures.
• Perform claim rework calculations and adjustments across all dollar amounts for unsolicited overpayment refunds.
• Follow through to resolution on medical claim overpayments, underpayments, and other irregularities.
• Respond to telephone and/or written inquiries related to preapprovals, prior 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.
• Utilize available resource materials and tools to manage job responsibilities.
• Handle assigned customer service inquiries and issues.

Qualifications

• 3+ years of medical claims processing experience.
• 2+ years of hands-on claim adjustment and rework experience.
• 2+ years of experience in a production environment with volume and accuracy standards.
• Demonstrated experience researching and resolving claim issues from initiation through resolution.
• Ability to interpret and apply guidelines related to eligibility, coverage, and benefits.
• Strong attention to detail.

Preferred Qualifications

• 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 processes.

Education

• High school diploma or equivalent required.

Pay Range

The typical pay range for this role is: $18.50 - $38.82. 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.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.