Senior Claims Benefit Specialist - Checkwork/Refund

Join Us At Cvs Health

We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

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.

Key Responsibilities

• 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.

Required Qualifications

• 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

Preferred Qualifications

• 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

Education

• Associate degree or equivalent experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$18.50 - $42.35

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great Benefits For Great People

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.