Strategic Reinsurance & Stoploss Claims Specialist

CVS Health; Dover; On-site; GBP 19,000 - 44,000; Full time

Benefits offered by this job

Bonus eligibility

Job summary

CVS Health is hiring for a Reinsurance/Stoploss Claims Adjuster to review, adjust, and adjudicate complex medical claims across high-dollar ranges. You’ll apply medical necessity guidelines, verify eligibility, identify discrepancies, and partner with teams to ensure accurate settlements.

You'll handle inquiries, respond to pre-authorizations and appeals, and contribute to training and mentoring. This full-time role offers comprehensive benefits and a path to growth within a global health leader.

Qualifications

• 2+ years medical claim processing experience.
• 2+ years in a production environment.

Responsibilities

• Review and adjust Reinsurance/Stoploss medical claims.
• Apply medical necessity guidelines and determine coverage.
• Perform claim re-work calculations.
• Research plan year and interpret complex plan language.
• Handle overpayments, underpayments, and irregularities.
• Review contract language to confirm overpayments.
• Partner with business functions on pricing and payment adjustments.
• Answer inquiries about pre-authorizations, reconsiderations, or appeals.
• May deliver training or mentor staff.
• Utilize resources to manage responsibilities.

Skills

Medical claims processing

Production environment experience

Education

Associate degree or equivalent experience

Job description

CVS Health is hiring for a Reinsurance/Stoploss Claims Adjuster to review, adjust, and adjudicate complex medical claims across high-dollar ranges. You’ll apply medical necessity guidelines, verify eligibility, identify discrepancies, and partner with teams to ensure accurate settlements.

You'll handle inquiries, respond to pre-authorizations and appeals, and contribute to training and mentoring. This full-time role offers comprehensive benefits and a path to growth within a global health leader.