Complex Reinsurance & Stop-Loss Claims Specialist

CVS Health; Annapolis (MD); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, ensuring accurate adjudication and compliance. You will collaborate with key business functions to resolve discrepancies and respond to customer inquiries.

The role emphasizes expertise in cost containment, plan language interpretation, and accurate claim adjustments, with 40 hours weekly and full-time benefits.

Qualifications

• 2+ years medical claim processing experience.
• 2+ years in a production environment.
• Proven ability to handle multiple assignments competently and efficiently.
• Strong communication and interpersonal skills.

Responsibilities

• Review and adjust complex Reinsurance/Stoploss medical claims.
• Apply medical necessity guidelines and determine coverage.
• Handle customer inquiries and concerns.
• Perform claim adjustments and re-work calculations.
• Research plan year, payments, and interpret plan language.
• Address overpayments, underpayments, and irregularities.
• Interpret provider contracts to verify overpayments.
• Collaborate with functions to ensure pricing and payments accuracy.
• Process relevant correspondence and adjustments.
• Handle pre-approvals/pre-authorizations inquiries.
• Ensure compliance and proper payments.
• May train or mentor junior staff.
• May provide job shadowing and utilize resources.

Skills

Medical claim processing

Multitasking

Communication skills

Education

Associate degree or equivalent experience

Tools

DG system

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, ensuring accurate adjudication and compliance. You will collaborate with key business functions to resolve discrepancies and respond to customer inquiries.

The role emphasizes expertise in cost containment, plan language interpretation, and accurate claim adjustments, with 40 hours weekly and full-time benefits.