Reinsurance & Stoploss Claims Specialist

CVS Health; Bozeman (MT); 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 detail-oriented Reinsurance/Stoploss Claims Specialist to review, research, and adjust complex medical claims. You will adjudicate high-dollar claims, apply medical necessity guidelines, and collaborate with internal teams to ensure accurate pricing and payments.

The role involves handling inquiries, pre-authorizations, and compliance across customer service platforms. 40 hours weekly, full-time in a production environment.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims across dollar levels.
• Adjudicate high-dollar complex claims per processing guidelines and cost containment measures.
• Collaborate with key functions to ensure accuracy and resolve discrepancies.
• Handle inquiries, pre-authorizations, reconsiderations, or appeals and ensure compliant payments.

Skills

Medical claim processing

Production environment

Education

Associate degree

Job description

CVS Health is seeking a detail-oriented Reinsurance/Stoploss Claims Specialist to review, research, and adjust complex medical claims. You will adjudicate high-dollar claims, apply medical necessity guidelines, and collaborate with internal teams to ensure accurate pricing and payments.

The role involves handling inquiries, pre-authorizations, and compliance across customer service platforms. 40 hours weekly, full-time in a production environment.