Senior Claims Benefit Specialist - Checkwork/Refund

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 coll...