Reinsurance & Stop-Loss Claims Specialist

CVS Health; Columbus (OH); Sur place; USD 25 000 - 58 000; Plein temps

Avantages offerts par ce poste

Bonus program

Healthcare benefits

Résumé du poste

CVS Health in Columbus, OH, is seeking a certified claims professional to review, research, and adjust complex Reinsurance/Stoploss medical claims, splitting them into multiple statuses and adjudicating high-dollar cases in accordance with processing guidelines. You will collaborate with key business functions to ensure accuracy in pricing and payments, handle inquiries, and ensure compliance.

This full-time role offers a 40-hour work week with a comprehensive benefits package and eligibility

Qualifications

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

Responsabilités

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Adjudicate high-dollar complex, sensitive, and/or specialized medical claims.
• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amounts.
• Apply medical necessity guidelines, determine coverage, verify eligibility, and identify discrepancies.
• Research and determine plan year, compare payments, and interpret complex plan language.
• Handle inquiries related to pre-approvals/pre-authorizations, reconsiderations, or appeals.

Connaissances

Medical claim processing

Production environment

Formation

Associate degree or equivalent experience

Description du poste

CVS Health in Columbus, OH, is seeking a certified claims professional to review, research, and adjust complex Reinsurance/Stoploss medical claims, splitting them into multiple statuses and adjudicating high-dollar cases in accordance with processing guidelines. You will collaborate with key business functions to ensure accuracy in pricing and payments, handle inquiries, and ensure compliance.

This full-time role offers a 40-hour work week with a comprehensive benefits package and eligibility