Reinsurance & Stop-Loss Claims Specialist

Internationalinsuranceprofessionals; Frankfort (KY); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review and adjust complex medical claims, collaborating with cross-functional teams to ensure accuracy and resolve discrepancies. You will handle customer inquiries and apply guidelines for coverage, eligibility, and cost containment.

The role emphasizes accuracy, communication, and adherence to compliance, with a comprehensive benefits package for a full-time schedule.

Qualifications

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

Responsibilities

• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amount levels using claims processing expertise.
• Apply medical necessity guidelines, determine coverage, verify eligibility, and apply cost containment measures.
• Conduct re-work calculations for Reinsurance/Stoploss claims.
• Research plan year, compare client payments with Stoploss carrier payments, interpret plan language for adjustments.
• Address overpayments, underpayments, and irregularities; ensure proper disposition.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Tools

DG system claims processing

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review and adjust complex medical claims, collaborating with cross-functional teams to ensure accuracy and resolve discrepancies. You will handle customer inquiries and apply guidelines for coverage, eligibility, and cost containment.

The role emphasizes accuracy, communication, and adherence to compliance, with a comprehensive benefits package for a full-time schedule.