Reinsurance & Stop-Loss Claims Specialist

CVS Health; Seattle (WA); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health seeks an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will apply medical necessity guidelines, determine coverage, verify eligibility, and reconcile rework with cross‑functional teams to ensure accurate handling.

The role focuses on high-dollar, sensitive adjustments with adherence to claim processing guidelines. This full-time position offers 40 hours per week, a comprehensive benefits package including medical, dental,

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Collaborate with business functions to ensure accuracy in adjustments.
• Handle inquiries and perform claim adjustments across all dollar levels.
• Ensure compliance and manage rework, overpayments, and underpayments.

Skills

Medical claim processing

Production environment experience

Multiple claim adjustments/rework

Education

Associate degree or equivalent experience

Tools

DG system claims processing

Reinsurance/Stop loss systems

Job description

CVS Health seeks an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will apply medical necessity guidelines, determine coverage, verify eligibility, and reconcile rework with cross‑functional teams to ensure accurate handling.

The role focuses on high-dollar, sensitive adjustments with adherence to claim processing guidelines. This full-time position offers 40 hours per week, a comprehensive benefits package including medical, dental,