Overpayment Recovery & Claims Specialist

CVS Health; Philadelphia (Philadelphia County); On-site; USD 25,000 - 53,000; Full time

Job summary

CVS Health is seeking a detail-oriented Overpayment Recovery Specialist to review and allocate refunds from overpayments, including complex cases. You will partner with vendors and internal units to secure recoveries, ensuring compliance with policies and procedures while maintaining quality and accuracy.

Responsibilities include handling high-volume calls and written inquiries, performing claim adjustments, and applying medical necessity guidelines.

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 with limited supervision
• Partner with internal units, vendors, and liaisons to recover funds and 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 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, determine coverage, verify eligibility, identify discrepancies, and apply cost containment measures
• 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

Outbound calls

Customer service

Attention to detail

Education

Associate degree or equivalent experience

Tools

DG system

Job description

CVS Health is seeking a detail-oriented Overpayment Recovery Specialist to review and allocate refunds from overpayments, including complex cases. You will partner with vendors and internal units to secure recoveries, ensuring compliance with policies and procedures while maintaining quality and accuracy.

Responsibilities include handling high-volume calls and written inquiries, performing claim adjustments, and applying medical necessity guidelines.