Reinsurance & Stop-Loss Claims Specialist

CVS Health; Michigan; Presencial; USD 25.000 - 58.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive benefits

Bonus eligibility

Descripción de la vacante

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims while ensuring accurate adjudication and compliant processing. You will collaborate with cross-functional teams to resolve discrepancies and respond to customer inquiries with professionalism.

The role requires 2+ years of medical claims processing in a production environment, strong analytical and communication skills, and full-time eligibility with a comprehensive benefits

Formación

• 2+ years medical claim processing experience.
• 2+ years in a production environment.
• Experience with Reinsurance/Stop loss preferred.
• Strong communication and interpersonal skills.

Responsabilidades

• Review and adjust complex Reinsurance/Stoploss medical claims.
• Apply medical necessity guidelines and determine coverage.
• Perform re-work calculations for complex claims.
• Research plan year and compare client vs Stoploss payments.
• Handle pre-approvals/pre-authorizations inquiries.
• Ensure compliance and proper payments per procedures.
• Mentor less experienced team members as needed.

Conocimientos

Medical claims processing

Production environment

Communication skills

Organizational skills

Educación

Associate degree or equivalent experience

Herramientas

DG system

Reinsurance/Stop loss knowledge

Descripción del empleo

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims while ensuring accurate adjudication and compliant processing. You will collaborate with cross-functional teams to resolve discrepancies and respond to customer inquiries with professionalism.

The role requires 2+ years of medical claims processing in a production environment, strong analytical and communication skills, and full-time eligibility with a comprehensive benefits