Healthcare Claims Recovery Specialist

CVS Health; Sioux Falls (SD); On-site; USD 25,000 - 53,000; Full time

Job summary

CVS Health in Sioux Falls, SD seeks an experienced overpayment recovery specialist to recover and allocate refunds, research inquiries, and conduct provider outreach. You will insure compliance with policies and drive timely recoveries in a high-volume setting.

Responsibilities include reviewing recovery items, coordinating with internal teams and vendors, and applying eligibility and coverage guidelines to support claim adjudication. Full-time role with comprehensive benefits.

Qualifications

• 3+ years of medical claims processing experience.
• 2+ years of medical claims adjustments or rework.
• 2+ years in a fast-paced, high-volume environment.
• Outbound calling experience with providers.
• Ability to interpret eligibility, coverage, and benefits.
• Detail-oriented with accuracy in multiple tasks.

Responsibilities

• Review, collect, and resolve overpayment recovery items via phone and written correspondence.
• Partner with internal units and vendors to recover funds and allocate refunds.
• Administer overpayment policies and communicate with members and providers.
• Manage overpayment work inventory and follow up to meet recovery goals.
• Coordinate escalated overpayments to drive resolution.
• Use analysis to solve complex recovery issues.
• Use reporting to track inventory, productivity, and results.
• Perform claim adjustments and rework calculations across dollar amounts.
• Apply medical necessity guidelines to support claim adjudication.
• Process complex provider refunds and returned checks.
• Review provider contract language to validate overpayments.
• Deliver recovery training for less experienced team members.
• Handle customer service inquiries and issues.

Skills

Medical claims processing

Claims adjustments

Outbound calls

Customer service

Eligibility rules

Detail oriented

Education

Associate degree

Tools

DG system claims processing

Job description

CVS Health in Sioux Falls, SD seeks an experienced overpayment recovery specialist to recover and allocate refunds, research inquiries, and conduct provider outreach. You will insure compliance with policies and drive timely recoveries in a high-volume setting.

Responsibilities include reviewing recovery items, coordinating with internal teams and vendors, and applying eligibility and coverage guidelines to support claim adjudication. Full-time role with comprehensive benefits.