Reinsurance & Stop-Loss Claims Specialist

CVS Health; Arizona; 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

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting claims into multiple statuses and working with key business functions to ensure accuracy.

Responsibilities include applying medical necessity guidelines, determining coverage, verifying eligibility, performing rework calculations, and addressing customer inquiries with a focus on precision and compliance.

Qualifications

• 2+ years medical claim processing experience.
• 2+ experience in a production environment.
• Strong attention to detail and accuracy in claims work.

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Split claims into multiple claim statuses and adjudicate high-dollar cases.
• Apply medical necessity guidelines and determine coverage.
• Verify eligibility and identify discrepancies to apply cost containment measures.
• Perform re-work calculations and reconcile payments.
• Interpret complex plan language for accurate adjustments.
• Handle inquiries related to pre-approvals, reconsiderations, or appeals.

Skills

Medical claim processing

Production environment

Communication

Customer service

Education

Associate degree or equivalent experience

Tools

DG system

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting claims into multiple statuses and working with key business functions to ensure accuracy.

Responsibilities include applying medical necessity guidelines, determining coverage, verifying eligibility, performing rework calculations, and addressing customer inquiries with a focus on precision and compliance.