Reinsurance & Stop-Loss Claims Specialist

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

Job summary

CVS Health in the United States is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting claims into multiple statuses and adjudicating high-dollar items.

You will collaborate with key business functions to ensure accuracy in adjustments, apply medical necessity guidelines, verify eligibility, and handle inquiries while ensuring compliance and timely resolutions.

Qualifications

• Associate degree or equivalent experience.
• 2+ years medical claim processing experience.
• 2+ years in a production environment.

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Adjudicate high-dollar complex, sensitive, and/or specialized medical claims.
• Collaborate with key business functions to ensure accuracy in claim adjustments.
• Handle customer inquiries and concerns.
• Perform claim adjustments across all dollar amounts on customer service platforms.
• Apply medical necessity guidelines, determine coverage, verify eligibility.
• Research plan years and interpret complex plan language.
• Follow through on overpayments, underpayments, and irregularities.
• Mentor less experienced team members.
• Utilize resource materials to manage responsibilities.

Skills

Medical claim processing

Production environment

Education

Associate degree or equivalent experience

Job description

CVS Health in the United States is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting claims into multiple statuses and adjudicating high-dollar items.

You will collaborate with key business functions to ensure accuracy in adjustments, apply medical necessity guidelines, verify eligibility, and handle inquiries while ensuring compliance and timely resolutions.