Medical Reinsurance & Stop-Loss Claims Specialist

CVS Health; Eagle (ID); Vor Ort; USD 25.000 - 58.000; Vollzeit

Benefits dieser Stelle

Bonus eligible

Comprehensive benefits

Paid time off

Retirement savings options

Zusammenfassung

CVS Health in Idaho seeks a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, ensuring accuracy in adjustments across high-dollar cases. You will collaborate with cross-functional teams, apply medical necessity guidelines, verify eligibility, and handle inquiries related to approvals and appeals.

This full-time role emphasizes compliance, cost containment, and professional mentorship, with a comprehensive benefits package and bonus eligibility.

Qualifikationen

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

Aufgaben

• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amounts on customer service platforms using technical and claims processing expertise.
• Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies and apply cost containment measures.
• Perform Reinsurance/Stoploss medical claim re-work calculations.
• Research plan year, compare client payments vs Stoploss payments, and interpret complex plan language for accurate adjustments.
• Complete overpayments/underpayments adjustments and resolve irregularities.
• Review contract language with provider contracts to confirm overpayments and allocate refunds.
• Partner with functions to ensure pricing, payment, and handling of adjustments are accurate.
• Handle inquiries related to pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and that payments follow company procedures.
• Manage external correspondence for the Adjustments department and perform required actions.
• Deliver training and mentor less experienced staff; provide job shadowing when needed.
• Use resource materials to manage duties.

Kenntnisse

Medical claims processing

Attention to detail

Communication skills

Multitasking

Customer service

Ausbildung

Associate degree or equivalent experience

Tools

DG system claims processing

Reinsurance/Stoploss familiarity

Jobbeschreibung

CVS Health in Idaho seeks a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, ensuring accuracy in adjustments across high-dollar cases. You will collaborate with cross-functional teams, apply medical necessity guidelines, verify eligibility, and handle inquiries related to approvals and appeals.

This full-time role emphasizes compliance, cost containment, and professional mentorship, with a comprehensive benefits package and bonus eligibility.