Reinsurance & Stoploss Claims Specialist

CVS Health; Lorida (FL); On-site; USD 26,000 - 58,000; Full time

Benefits offered by this job

Bonus eligibility

Comprehensive benefits package

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting claims into multiple statuses and ensuring accuracy in pricing and payments. You will partner with cross-functional teams to resolve discrepancies and handle customer inquiries with professionalism.

The role requires 2+ years in medical claim processing and a background in a production environment.

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims across dollar levels.
• Collaborate with key business functions to ensure accuracy in claim adjustments and reconciliations.
• Handle customer inquiries related to pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Follow compliance requirements and ensure payments align with company procedures.
• Mentor less experienced staff and provide job shadowing as needed.

Skills

Medical claim processing

Production environment

Education

Associate degree or equivalent experience

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims, splitting claims into multiple statuses and ensuring accuracy in pricing and payments. You will partner with cross-functional teams to resolve discrepancies and handle customer inquiries with professionalism.

The role requires 2+ years in medical claim processing and a background in a production environment.