Senior Claims Benefit Specialist – Checkwork, Refund

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🕒 4 dias atrás

🥔 Idaho, Kansas, +1 estados a mais – Remoto

🥔 Idaho – Remote 🌪️ Kansas – Remote 🤠 Texas – Remote

💵 $18 - $42 / hora

⏰ Tempo Integral

🟠 Sênior

💻 Suporte de TI

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CVS Health

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1963

⚕️ Seguro de Saúde

🛒 Varejo

🧘 Bem-estar

Healthcare Insurance • Retail • Wellness

CVS Health é uma empresa líder de saúde nos Estados Unidos, dedicada a ampliar o acesso e a acessibilidade ao cuidado. A empresa adota uma abordagem abrangente que inclui serviços de saúde, seguro saúde e gestão de benefícios farmacêuticos (PBM). Por meio de suas subsidiárias, como Aetna e CVS Caremark, a CVS Health oferece uma variedade de serviços que promovem o bem-estar, a gestão de condições de saúde e a cobertura acessível de medicamentos prescritos. A CVS Health opera farmácias de bairro, oferece serviços de farmácia por correspondência e gerencia programas de medicamentos de especialidade, com o objetivo de tornar o cuidado com a saúde conveniente e acessível para todos. Movida pela missão de conectar pessoas a serviços essenciais de cuidado, a CVS Health está comprometida em fomentar comunidades mais saudáveis e apoiar o bem-estar de todas as pessoas.

Descrição

• 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

🎯 Requisitos

• 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

🏖️ Benefícios

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families