Reinsurance & Stop-Loss Claims Specialist

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

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting into statuses, and adjudicate high-dollar cases in line with processing guidelines. You will collaborate with stakeholders to ensure accuracy in claim adjustments and respond to customer inquiries.

Additionally, you will verify eligibility, apply cost containment measures, manage rework discrepancies, interpret contract language, and support cross-functional pricing and

Qualifications

• 2+ years medical claim processing experience.
• 2+ experience in a production environment.
• Familiarity with Reinsurance/Stop loss medical claims.
• Effective communications, organizational, and interpersonal skills.

Responsibilities

• Review and adjust Reinsurance/Stoploss medical claims across all dollar levels.
• Apply medical necessity guidelines and determine coverage.
• Perform re-work calculations for Stoploss claims.
• Research plan year, compare client payments with Stoploss carriers, and interpret plan language.

Skills

Medical claim processing

Production environment experience

Communication skills

Analytical skills

Education

Associate degree or equivalent experience

Tools

DG system

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting into statuses, and adjudicate high-dollar cases in line with processing guidelines. You will collaborate with stakeholders to ensure accuracy in claim adjustments and respond to customer inquiries.

Additionally, you will verify eligibility, apply cost containment measures, manage rework discrepancies, interpret contract language, and support cross-functional pricing and