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
Pursue the recovery and allocation of overpaid dollars, and non-routine and complex refunds. Manage, monitor, and work overpayment items. Partner with third-party vendors, research and respond to recovery inquiries. Make outbound calls to providers; track and conduct follow-ups to recover funds. Collaborate with key business functions on escalated overpayments to coordinate recovery efforts. May handle customer service inquiries and problems.
Fundamental Components
- Review, collect, and resolve overpay or recovery conflicting, missing or inaccurate information via telephone or written correspondence with limited degree of supervision.
- Partner with internal customers/business units, third party vendors, and liaisons to recover and fully allocate refunds.
- Administer overpayment recovery policy and procedures, telephone and written correspondence to members, providers, and other insurers.
- Manage overpayment work; collaborate and conduct provider outreach to achieve business goals.
- Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures.
- Use a systematic approach in solving problems through analysis and evaluation of alternate solutions.
- Utilize available reports to track inventory and recovery results.
- May deliver recovery training programs for less experienced team members.
- Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise.
- Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
- Performs medical claim re-work calculations.
- Process complex non-routine Provider Refunds and Returned Checks.
- Review and interprets medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks.
- Utilize all resource materials to manage job responsibilities.
Required Qualifications
- 3+ years of medical claims processing experience
2+ years of medical claims adjustments and/or rework experience
2 years of experience working in a fast-paced, deadline-driven, high-volume environment
Experience conducting outbound calls, including provider outreach
Experience handling customer service inquiries via phone and/or written correspondence
Ability to interpret and apply guidelines related to eligibility, coverage, and benefits
Demonstrated ability to manage multiple assignments with a high degree of accuracy and attention to detail
Preferred Qualifications
- Independent decision-making skills.
- Effective communications, organizational, and interpersonal skills.
- Familiarity with posting of refunds.
- Familiarity with overpayments recovery.
- DG system claims processing experience.
Education
- Associate degree or High School Diploma and equivalent experience.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$18.50 - $42.35This 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
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