Reinsurance & Stoploss Claims Specialist

CVS Health; Orangeburg (SC); On-site; USD 26,000 - 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, ensuring accuracy and compliance across all processing steps. You will collaborate with various business functions to resolve discrepancies and respond to customer inquiries.

Responsibilities include applying medical necessity guidelines, verifying eligibility, and performing re-work calculations, while handling overpayments and underpayments with precision.

Qualifications

• Minimum 2+ years of medical claim processing experience.
• Minimum 2+ years of production environment experience.
• Strong communication and interpersonal skills.

Responsibilities

• Review and adjust Reinsurance/Stoploss medical claims across dollar levels using claims processing expertise.
• Apply medical necessity guidelines, verify eligibility, identify discrepancies in claim adjudication.
• Perform re-work calculations and resolve overpayments/underpayments.
• Research plan year, compare payments by client vs. carriers, and interpret complex plan language.
• Handle inquiries related to pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and that all payments follow CVS Health procedures; provide training to teammates if needed.

Skills

Medical claims processing

Production environment experience

Effective communication skills

Education

Associate degree or equivalent experience

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review and adjust complex medical claims, ensuring accuracy and compliance across all processing steps. You will collaborate with various business functions to resolve discrepancies and respond to customer inquiries.

Responsibilities include applying medical necessity guidelines, verifying eligibility, and performing re-work calculations, while handling overpayments and underpayments with precision.