Medical Claims Recovery Specialist

CVS Health; Charleston (WV); On-site; USD 25,000 - 53,000; Full time

Job summary

CVS Health is seeking an experienced overpayment recovery specialist to review, allocate, and recover refunds from complex and non-routine scenarios. You will collaborate with vendors and internal partners to secure recoveries, ensure compliance, and handle provider outreach.

The role requires strong claims processing or adjustments experience, meticulous attention to detail, and the ability to manage multiple priorities 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 via phone and written correspondence.
• Partner with internal units, vendors, and liaisons to recover funds and allocate refunds.
• Administer overpayment recovery policies and procedures with members, providers, and insurers.
• Manage overpayment work inventory and complete timely follow-ups.
• Coordinate with key business functions on escalated overpayments to drive resolution.
• Use analysis 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.
• Apply medical necessity guidelines and verify eligibility to support adjudication.
• Process complex provider refunds and returned checks.
• Review provider contracts to validate overpayments and refund allocations.

Skills

Medical claims processing

Claims adjustments/rework

Outbound provider outreach

Customer service

Detail-oriented

Education

Associate degree or equivalent experience

Tools

DG system claims processing

Job description

CVS Health is seeking an experienced overpayment recovery specialist to review, allocate, and recover refunds from complex and non-routine scenarios. You will collaborate with vendors and internal partners to secure recoveries, ensure compliance, and handle provider outreach.

The role requires strong claims processing or adjustments experience, meticulous attention to detail, and the ability to manage multiple priorities in a fast-paced environment.