Reinsurance & Stoploss Claims Specialist

CVS Health; Montana; On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

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 per processing guidelines, while handling customer inquiries. Collaborate with cross-functional teams to reconcile rework discrepancies and apply cost containment measures.

Based in Montana, this full-time role applies medical necessity guidelines, determines coverage, and handles overpayments/underpayments.

Qualifications

• 2+ years medical claim processing experience.
• 2+ years experience in a production environment.
• Knowledge of eligibility verification, medical necessity guidelines and cost containment.

Responsibilities

• Review and adjust complex Reinsurance/Stoploss medical claims across all dollar levels.
• Split claims into multiple statuses and adjudicate in accordance with processing guidelines.
• Identify discrepancies, perform rework calculations and reconcile payments.
• Handle inquiries by phone and written correspondence from customers and providers.
• Collaborate with key business functions to ensure accuracy in pricing, payment and adjustments.
• Provide training or mentorship to less experienced team members.

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 per processing guidelines, while handling customer inquiries. Collaborate with cross-functional teams to reconcile rework discrepancies and apply cost containment measures.

Based in Montana, this full-time role applies medical necessity guidelines, determines coverage, and handles overpayments/underpayments.