Reinsurance & Stop-Loss Claims Specialist

CVS Health; Vermont; 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 options

Wellness programs

Job summary

CVS Health is seeking a dedicated Adjuster for Reinsurance/Stoploss claims in a full-time capacity. The role requires reviewing complex medical claims, applying eligibility guidelines, and performing adjustments while maintaining compliance with processing guidelines.

You will handle inquiries, support pre-authorizations, and partner with cross-functional teams to ensure accurate pricing and reimbursements. Strong attention to detail and healthcare knowledge are essential.

Qualifications

• 2+ years medical claim processing experience.
• 2+ years experience in a production environment.
• Familiarity with Reinsurance/Stop loss medical claims.

Responsibilities

• Review and adjust complex Reinsurance/Stoploss medical claims.
• Apply medical necessity guidelines and determine coverage.
• Process rework calculations and resolve discrepancies.
• Assist with inquiries and pre-approvals related to claims.
• Collaborate with business functions to ensure pricing accuracy.

Skills

Medical claim processing

Production environment experience

Communication skills

Education

Associate degree or equivalent experience

Job description

CVS Health is seeking a dedicated Adjuster for Reinsurance/Stoploss claims in a full-time capacity. The role requires reviewing complex medical claims, applying eligibility guidelines, and performing adjustments while maintaining compliance with processing guidelines.

You will handle inquiries, support pre-authorizations, and partner with cross-functional teams to ensure accurate pricing and reimbursements. Strong attention to detail and healthcare knowledge are essential.