Reinsurance & Stoploss Claims Specialist

Internationalinsuranceprofessionals; Hartford (CT); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Comprehensive benefits

Paid time off

Retirement savings options

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting into statuses and adjudicating high-dollar cases.

You will apply medical necessity guidelines, verify eligibility, resolve discrepancies, and collaborate across teams to ensure accurate pricing, payments, and compliance; full-time role with benefits and eligibility for bonus.

Qualifications

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

Responsibilities

• Review and adjust Reinsurance/Stoploss medical claims.
• Split claims into multiple statuses and adjudicate.
• Verify eligibility and apply cost containment measures.
• Handle inquiries related to pre-approvals, reconsiderations or appeals.
• Collaborate with business functions to ensure accurate adjustments.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Tools

DG system

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting into statuses and adjudicating high-dollar cases.

You will apply medical necessity guidelines, verify eligibility, resolve discrepancies, and collaborate across teams to ensure accurate pricing, payments, and compliance; full-time role with benefits and eligibility for bonus.