Expert Reinsurance & Stoploss Medical Claims Adjustor

CVS Health; Augusta (ME); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Benefits package

Bonus eligibility

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Specialist to review and adjust complex medical claims, applying guidelines and verifying eligibility while collaborating with key business functions to ensure accuracy in adjustments.

The role handles high-dollar, sensitive claims, processes inquiries, and ensures compliance with company procedures. A focus on accuracy and problem-solving is essential for success.

Qualifications

• 2+ years medical claim processing experience.
• 2+ years experience in a production environment.
• 2+ years processing medical claims adjustments/rework.
• Familiarity with Reinsurance/Stop loss medical claims.
• DG system claims processing experience.

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims across dollar levels.
• Apply medical necessity guidelines and determine coverage; verify eligibility and apply cost containment measures.
• Perform re-work calculations for Reinsurance/Stoploss medical claims.
• Interpret plan language and ensure accurate adjustments and refunds.
• Handle pre-approvals/pre-authorizations inquiries and appeals.
• Ensure compliance and proper payments per company procedures.
• Provide mentorship or training to less experienced staff.

Skills

Medical claim processing

Production environment experience

Claims adjustments/rework

Communication skills

Analytical skills

Education

Associate degree or equivalent experience

Tools

DG system

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Specialist to review and adjust complex medical claims, applying guidelines and verifying eligibility while collaborating with key business functions to ensure accuracy in adjustments.

The role handles high-dollar, sensitive claims, processes inquiries, and ensures compliance with company procedures. A focus on accuracy and problem-solving is essential for success.