Reinsurance & Stoploss Claims Specialist

CVS Health; Montpelier (VT); 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

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review and adjust complex medical claims, splitting them into statuses and adjudicating high-dollar cases. You will collaborate with multiple business functions to ensure accurate adjustments and resolve rework discrepancies.

You will apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and apply cost containment measures to support accurate adjudication and timely responses to

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Split claims into multiple claim statuses and adjudicate high-dollar complex claims.
• Apply medical necessity guidelines and determine coverage for claims.
• Perform claim re-work calculations for stoploss claims.
• Research plan year and compare client payments with stoploss carriers.
• Handle inquiries related to pre-approvals, reconsiderations or appeals.
• Ensure compliance and proper payment processing per company procedures.

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 and adjust complex medical claims, splitting them into statuses and adjudicating high-dollar cases. You will collaborate with multiple business functions to ensure accurate adjustments and resolve rework discrepancies.

You will apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and apply cost containment measures to support accurate adjudication and timely responses to