Medical Claims Processor

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 colleagues who care deeply, innovate with purpose, hold themselves accountable and prioritize safety and quality in everything they do.

Job Summary 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.

Required 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.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range $18.50 - $38.82

Benefits This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.