Senior Claims Benefit Specialist – Checkwork/Refund

CVS Health

Senior Claims Benefit Specialist responsible for processing complex medical claims and refunds at CVS Health. Collaborating with key business functions to resolve discrepancies and ensure compliance.

Posted 5/5/2026full-timeRemote • Idaho, Kansas, Texas • 🇺🇸 United StatesSenior💰 $19 - $42 per hourWebsite

About the role

Key responsibilities & impact

Review and complete provider-solicited and unsolicited overpayment refunds and returned checks
Research, resolve, and adjudicate complex, sensitive, and/or specialized medical claims in accordance with claims-processing guidelines
Partner with key business functions, ensure accurate posting of overpayment refunds, reconcile discrepancies, and respond to internal and provider inquiries
Process complex, non-routine provider refunds and returned checks
Review and interpret contract language to validate overpayments and allocate refund checks appropriately
Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply cost-containment measures to support claim adjudication
Ensure compliance requirements are met and that payments/refunds follow company practices and procedures
Perform claim rework calculations and adjustments across all dollar amounts for unsolicited overpayment refunds
Follow through to completion on medical claim overpayments, underpayments, and other irregularities
Respond to telephone and/or written inquiries related to pre-approvals/pre-authorizations, reconsiderations, and appeals
Review assigned claims data mining work that may result in claim adjustments and complete resulting adjustments as appropriate
Process medical claim adjustments on customer service platforms using technical and claims-processing expertise
Provide overpayment refund training, mentoring, and job shadowing support for less experienced colleagues, as assigned
Use available resource materials and tools to manage job responsibilities
Handle customer service inquiries and issues assigned

Requirements

What you’ll need

3+ years of medical claims processing experience
2+ years of hands-on claim adjustments/rework experience
2+ years in a production environment (volume + accuracy expectations)
Demonstrated experience researching and resolving claim issues end-to-end
Ability to interpret and apply guidelines related to eligibility, coverage, and benefits
High attention to detail
Experience reviewing and researching overpayment refunds
DG system claims processing experience
Ability to manage multiple assignments accurately and efficiently
Effective communication, organizational, and interpersonal skills
Familiarity with overpayment recovery

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
comprehensive benefits package

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical claims processingclaim adjustmentsclaim reworkeligibility verificationcost-containment measuresdata miningoverpayment refundsclaims-processing guidelinescontract language interpretationclaim adjudication

Soft Skills

attention to detaileffective communicationorganizational skillsinterpersonal skillsability to manage multiple assignmentsproblem-solvingmentoringtrainingresearchingresolving claim issues