Reinsurance & Stoploss Claims Specialist

Internationalinsuranceprofessionals; Dover (DE); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Bonus eligibility

Job summary

CVS Health is seeking a Claim Adjuster for Reinsurance/Stoploss to review and adjust complex medical claims, ensuring accurate adjudication and compliance with processing guidelines. You will collaborate with cross-functional teams, apply medical necessity guidelines, and address customer inquiries while supporting cost containment efforts.

Ideal candidates have 2+ years in medical claim processing and experience in a production environment, with an Associate degree or equivalent.

Qualifications

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

Responsibilities

• Review and adjust complex Reinsurance/Stoploss medical claims across all dollar amounts.
• Apply medical necessity guidelines, determine coverage, verify eligibility and apply cost containment measures.
• Handle customer inquiries and concerns regarding claims.
• Collaborate with key business functions to ensure accuracy in claim adjustments.
• Mentor less experienced team members and deliver job shadowing where appropriate.

Skills

Medical claims processing

Production environment experience

Team collaboration

Education

Associate degree or equivalent experience

Tools

DG system claims processing

Job description

CVS Health is seeking a Claim Adjuster for Reinsurance/Stoploss to review and adjust complex medical claims, ensuring accurate adjudication and compliance with processing guidelines. You will collaborate with cross-functional teams, apply medical necessity guidelines, and address customer inquiries while supporting cost containment efforts.

Ideal candidates have 2+ years in medical claim processing and experience in a production environment, with an Associate degree or equivalent.