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. Handle customer service inquiries and issues assigned **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.