Complex Reinsurance & Stoploss Claims Specialist

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health in Salem, NH is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will collaborate with cross-functional teams to ensure accuracy in adjustments, assist with inquiries, and enforce claim processing guidelines.

The role requires 2+ years of medical claims processing in a production environment, an Associate degree or equivalent, and a 40-hour work week. Eligible for CVS Health bonus and comprehensive benefits.

Qualifications

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

Responsibilities

• Review and adjust Reinsurance/Stoploss medical claims across all dollar amounts.
• Apply medical necessity guidelines and determine coverage.
• Perform re-work calculations for claims adjustments.
• Research plan year and compare client vs Stoploss carrier payments.
• Handle pre-approvals, reconsiderations, or appeals inquiries.
• Ensure compliance and accurate payments per company procedures.
• Provide training or mentorship as needed.

Skills

Medical claims processing

Production environment

Education

Associate degree or equivalent experience

Job description

CVS Health in Salem, NH is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will collaborate with cross-functional teams to ensure accuracy in adjustments, assist with inquiries, and enforce claim processing guidelines.

The role requires 2+ years of medical claims processing in a production environment, an Associate degree or equivalent, and a 40-hour work week. Eligible for CVS Health bonus and comprehensive benefits.