Claims Recovery & Refunds Specialist

CVS Health; Clifton (TX); On-site; USD 25,000 - 53,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Other resources

Job summary

CVS Health is seeking an Overpayment Recovery Specialist to recover and allocate overpayments, respond to inquiries, and coordinate with vendors and internal teams. This role focuses on accuracy, compliance, and timely recovery efforts across complex refunds.

The position involves outbound provider outreach, adherence to policies, and collaboration with multiple business units to optimize recovery outcomes in a fast-paced environment.

Qualifications

• 3+ years of medical claims processing experience.
• 2+ year of medical claims adjustments and/or rework experience.
• 2+ year 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.

Responsibilities

• Review, collect, and resolve overpayment recovery items, including conflicting, missing, or inaccurate information, via phone and written correspondence with limited supervision.
• Partner with internal business units, vendors, and liaisons to recover funds and fully allocate refunds.
• Administer overpayment recovery policies and procedures, including written and phone correspondence with members, providers, and other insurers.
• Manage overpayment work inventory; monitor progress and complete timely follow-ups to achieve recovery goals.
• Coordinate with key business functions on escalated overpayments to drive resolution and recovery.
• Use analysis and evaluation of alternatives to solve complex, non-routine recovery issues.
• Use reporting to track inventory, productivity, and recovery results.
• Perform claim adjustments and rework calculations across all dollar amounts using claims processing expertise.
• Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and apply cost containment measures to support claim adjudication.
• Process complex provider refunds and returned checks.
• Review and interpret provider contract language to validate overpayments and support allocation of refund checks.
• Deliver recovery training for less experienced team members as needed.
• Handle customer service inquiries and issues assigned.

Skills

Medical claims processing

Claims adjustments/rework

High-volume environment

Outbound calls

Customer service inquiries

Eligibility/coverage guidance

Attention to detail

Education

Associate degree or equivalent experience

Tools

DG system claims processing

Job description

CVS Health is seeking an Overpayment Recovery Specialist to recover and allocate overpayments, respond to inquiries, and coordinate with vendors and internal teams. This role focuses on accuracy, compliance, and timely recovery efforts across complex refunds.

The position involves outbound provider outreach, adherence to policies, and collaboration with multiple business units to optimize recovery outcomes in a fast-paced environment.