Reinsurance & Stop-Loss Claims Specialist

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Bonus program

Paid time off

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 adjudicating high-dollar cases. You will collaborate with key teams to ensure accuracy, resolve discrepancies, and handle customer inquiries with professionalism.

The role requires 2+ years of medical claims processing experience and an Associate degree or equivalent.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply cost containment measures.
• Performs Reinsurance/Stoploss medical claim re-work calculations.
• Research and determine plan year and interpret complex plan language for accurate adjustments.
• Follow through completion of claim overpayments, underpayments, or irregularities.
• Review and interpret medical contract language with provider contracts to confirm overpayments.
• Partner with business functions to ensure accuracy in pricing and handling of adjustments.
• Handle relevant correspondences related to adjustments and inquiries.
• Handle telephone and written inquiries for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and that all payments adhere to company procedures.
• Manage external correspondence for the Adjustments department; research and take required actions.
• May deliver training or mentor for less experienced staff.
• May provide job shadowing to lesser experienced staff.

Skills

Medical claims 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, splitting claims into multiple statuses and adjudicating high-dollar cases. You will collaborate with key teams to ensure accuracy, resolve discrepancies, and handle customer inquiries with professionalism.

The role requires 2+ years of medical claims processing experience and an Associate degree or equivalent.