Senior Claim Benefit Specialist – Checkwork, Refund

This is a fully remote position, open to applicants in Alabama, +33 more locations.

📋 Description

• Evaluate and finalize provider-solicited and unsolicited overpayment refunds along with returned checks.

• Investigate, resolve, and adjudicate intricate, sensitive, and/or specialized medical claims.

• Collaborate with essential business units to ensure the precise recording of overpayment refunds.

• Reconcile inconsistencies and address inquiries from both internal teams and providers.

• Manage complex, non-standard provider refunds and returned checks.

• Analyze and interpret contract language to verify overpayments and appropriately allocate refund checks.

• Implement medical necessity guidelines, determine coverage, conduct eligibility verification, identify discrepancies, and apply cost-containment strategies.

• Ensure compliance with requirements and that payments and refunds adhere to company policies and procedures.

• Execute claim rework calculations and adjustments across all monetary amounts.

• Address issues related to medical claim overpayments, underpayments, and other anomalies.

• Respond to inquiries regarding preapprovals, prior authorizations, reconsiderations, and appeals.

• Examine assigned claims data-mining tasks and complete necessary adjustments.

• Process medical claim adjustments utilizing customer service platforms.

• Offer training, mentoring, and job-shadowing support related to overpayment refunds to less experienced colleagues as needed.

• Utilize available resources and tools to effectively manage responsibilities.

• Address assigned customer service inquiries and concerns.

⛳️ Requirements

• A minimum of 3 years of experience in medical claims processing.

• At least 2 years of direct experience in claim adjustment and rework.

• Over 2 years of experience in a production environment with established volume and accuracy standards.

• Proven history of researching and resolving claim issues from start to finish.

• Capability to interpret and apply guidelines related to eligibility, coverage, and benefits.

• Exceptional attention to detail.

• High school diploma or equivalent is required.

• Preferred: experience in reviewing and researching overpayment refunds.

• Preferred: experience with DG system claims processing.

• Preferred: ability to manage multiple tasks accurately and efficiently.

• Preferred: strong communication, organizational, and interpersonal abilities.

• Preferred: knowledge of overpayment recovery processes.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.