Complex Reinsurance & Stoploss Claims Adjuster

CVS Health; South Dakota; On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Health insurance

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health in the United States is seeking a Reinsurance/Stoploss Claims Specialist to review, adjust, and adjudicate complex medical claims, including high-dollar and sensitive cases. You will collaborate with multiple teams to ensure accurate claim adjustments, research contract language, and resolve discrepancies while addressing customer inquiries.

Ideal candidates have 2+ years of medical claims processing experience in a production setting, an Associate degree or relevant experience, and

Qualifications

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

Responsibilities

• Review, adjust, and adjudicate complex reinsurance/stoploss claims.
• Collaborate with key business functions to ensure accuracy in adjustments.
• Handle customer inquiries and concerns related to claims.
• Apply medical necessity guidelines and plan language to determine coverage.
• Research and resolve rework discrepancies and claim over-/underpayments.

Skills

Medical claim processing

Production environment

Education

Associate degree or equivalent experience

Job description

CVS Health in the United States is seeking a Reinsurance/Stoploss Claims Specialist to review, adjust, and adjudicate complex medical claims, including high-dollar and sensitive cases. You will collaborate with multiple teams to ensure accurate claim adjustments, research contract language, and resolve discrepancies while addressing customer inquiries.

Ideal candidates have 2+ years of medical claims processing experience in a production setting, an Associate degree or relevant experience, and