Medical Claims Adjuster - Reinsurance/Stop-Loss

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

Benefits offered by this job

Health benefits

Bonus eligibility

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims while collaborating with key business functions to ensure accuracy in adjustments. You will handle inquiries and perform detailed claim rework as needed.

The role requires 2+ years in medical claim processing and experience in a production environment, with an Associate degree or equivalent. This is a full-time position with competitive benefits and potential bonus eligibility.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Collaborate with key business functions to ensure accuracy in claim adjustments.
• Handle customer inquiries and concerns.
• Perform adjustments across all dollar amounts on customer service platforms.
• Apply medical necessity guidelines and determine coverage.
• Research and determine plan year and reconcile payments with Stoploss carriers.
• Ensure compliance with company practices and procedures.

Skills

Medical claim processing

Production environment

Education

Associate degree or equivalent experience

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims while collaborating with key business functions to ensure accuracy in adjustments. You will handle inquiries and perform detailed claim rework as needed.

The role requires 2+ years in medical claim processing and experience in a production environment, with an Associate degree or equivalent. This is a full-time position with competitive benefits and potential bonus eligibility.