Complex Stoploss & Reinsurance Claims Specialist

CVS Health; New Hampshire; On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health in the United States is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, including high-dollar cases. You will allocate claims across statuses, adjudicate with processing guidelines, and collaborate with key business functions to ensure accurate adjustments and resolve rework discrepancies.

This full-time role requires 2+ years of medical claims processing experience and an associate degree or equivalent.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Split claims into multiple claim statuses and adjudicate high-dollar cases.
• Collaborate with key business functions to ensure accuracy in adjustments.
• Handle customer inquiries and concerns related to claims.
• Follow compliance requirements and ensure proper payment handling.
• May provide training or mentoring to junior staff.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Job description

CVS Health in the United States is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, including high-dollar cases. You will allocate claims across statuses, adjudicate with processing guidelines, and collaborate with key business functions to ensure accurate adjustments and resolve rework discrepancies.

This full-time role requires 2+ years of medical claims processing experience and an associate degree or equivalent.