Reinsurance & Stoploss Claims Specialist

CVS Health; Richmond (VA); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental and vision

Paid time off

Retirement savings

Wellness programs

Job summary

CVS Health in Richmond, VA is seeking an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will collaborate with multiple functions to ensure accurate adjustments, handle inquiries, and ensure compliance with processing guidelines.

The role requires 2+ years of medical claim processing experience and exposure to a production environment. Comprehensive benefits including medical, dental, and vision coverage, paid time off, retirement

Qualifications

• Two or more years of medical claim processing experience.
• Two+ years in a production environment.

Responsibilities

• Review and adjust complex Reinsurance/Stoploss medical claims.
• Split claims into multiple statuses as needed.
• Adjudicate high-dollar, complex, sensitive claims per guidelines.
• Collaborate with key business functions for accurate adjustments.
• Assist with customer inquiries and concerns.
• Apply medical necessity guidelines and coverage determinations.
• Perform re-work calculations on claims as required.
• Research plan year and compare client vs. carrier payments.
• Interpret complex plan language for accurate handling.
• Ensure compliance and proper payments per company procedures.
• Provide training or mentorship on Reinsurance/Stoploss adjustments.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Job description

CVS Health in Richmond, VA is seeking an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will collaborate with multiple functions to ensure accurate adjustments, handle inquiries, and ensure compliance with processing guidelines.

The role requires 2+ years of medical claim processing experience and exposure to a production environment. Comprehensive benefits including medical, dental, and vision coverage, paid time off, retirement