Reinsurance & Stoploss Claims Specialist

CVS Health; Clayton (NM); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health is looking for a skilled professional to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will split claims into multiple statuses and adjudicate high-dollar cases using established guidelines in a collaborative environment with cross-functional partners.

Responsibilities include performing adjustments, verifying eligibility, applying cost containment measures, and addressing inquiries while ensuring compliance and accurate finalization of claims.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Adjudicate high-dollar complex medical claims per processing guidelines.
• Collaborate with key functions to ensure accuracy in claim adjustments and reconcile rework.
• Handle customer inquiries and concerns related to claims.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Job description

CVS Health is looking for a skilled professional to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will split claims into multiple statuses and adjudicate high-dollar cases using established guidelines in a collaborative environment with cross-functional partners.

Responsibilities include performing adjustments, verifying eligibility, applying cost containment measures, and addressing inquiries while ensuring compliance and accurate finalization of claims.