Complex Reinsurance & Stoploss Claims Specialist

CVS Health; Salem (OR); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Benefits package

Bonus eligibility

Paid time off

Job summary

CVS Health in Salem, Oregon is seeking an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, ensuring accurate adjudication and compliant processing.

You will collaborate with cross-functional teams to verify coverage, apply medical necessity guidelines, and resolve overpayments or underpayments while handling high-dollar claims and customer inquiries.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims across dollar amounts.
• Adjudicate high-dollar complex medical claims following guidelines.
• Apply medical necessity guidelines and determine coverage.
• Perform re-work calculations for stoploss claims.
• Identify discrepancies and reconcile rework/adjustments.
• Handle inquiries related to pre-approvals, reconsiderations, or appeals.
• Ensure all payments comply with company policies.

Skills

Medical claims processing

Production environment

Education

Associate degree or equivalent

Job description

CVS Health in Salem, Oregon is seeking an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, ensuring accurate adjudication and compliant processing.

You will collaborate with cross-functional teams to verify coverage, apply medical necessity guidelines, and resolve overpayments or underpayments while handling high-dollar claims and customer inquiries.