Complex Medical Claims Reinsurance/Stoploss Adjuster

CVS Health; Hydaburg (AK); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is seeking a claims Adjuster to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will split claims, determine coverage, verify eligibility, and apply cost-containment measures to support accurate adjudication. You will work with cross-functional teams to ensure pricing and payment accuracy.

The role handles high-dollar adjustments, complex language interpretation, and may mentor junior staff. 40-hour weeks with full-time benefits are provided.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims, splitting claims into multiple claim statuses.
• Adjudicate high-dollar complex, sensitive, and/or specialized medical claims in accordance with claim processing guidelines.
• Collaborate with key business functions to ensure accuracy in claim adjustments and reconcile rework discrepancies.
• Handle customer inquiries and concerns.
• Follow through completion of Reinsurance/Stoploss medical claim overpayments, underpayments, and any irregularities.
• Review and interpret medical contract language to confirm whether a claim is overpaid and allocate refunds.
• May provide job shadowing or mentorship to less experienced staff.

Skills

Medical claim processing

Production environment

Education

Associate degree

Job description

CVS Health is seeking a claims Adjuster to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will split claims, determine coverage, verify eligibility, and apply cost-containment measures to support accurate adjudication. You will work with cross-functional teams to ensure pricing and payment accuracy.

The role handles high-dollar adjustments, complex language interpretation, and may mentor junior staff. 40-hour weeks with full-time benefits are provided.