Reinsurance & Stoploss Medical Claims Adjudicator

CVS Health; Sioux Falls (SD); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Other resources based on eligibility

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims while collaborating with key business functions to ensure accuracy and resolve discrepancies.

The role involves handling customer inquiries, applying guidelines, and ensuring compliance. Anticipated weekly hours are 40, with a comprehensive benefits package and eligibility for bonus programs.

Qualifications

• 2+ years medical claim processing experience.
• 2+ experience in a production environment.
• 2+ years processing medical claims adjustments/rework.
• Familiarity with Reinsurance/Stop loss medical claims.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communications, organizational, and interpersonal skills.

Responsibilities

• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the Reinsurance/Stoploss claim adjudication process.
• Performs Reinsurance/Stoploss medical claim re-work calculations.
• Research and determine Reinsurance/Stoploss plan year, identify claim payments made by client versus the Stoploss carriers, and interpret complex plan language to ensure accurate handling of complex adjustments.
• Follow through completion of Reinsurance/Stoploss medical claim overpayments, underpayments, and any other irregularities.
• Review and interpret medical contract language using provider contracts to confirm whether a Reinsurance/Stoploss claim is overpaid to allocate refund checks.
• Partner with key business functions to ensure accuracy in pricing, payment, and handling of complex Reinsurance/Stoploss claim adjustments.
• Review and handle relevant correspondences assigned to the team that may result in adjustment to Reinsurance/Stoploss medical claims.
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures.
• Manage external correspondence assigned to the Adjustments department; research, triage, and perform required actions, including adjustments to medical claims.
• May deliver Reinsurance/Stoploss claims adjustment training and/or serve as a mentor for less experienced team members.
• May provide job shadowing to lesser experience staff.
• Utilize all resource materials to manage job responsibilities.

Skills

Medical claim processing

Production environment experience

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 while collaborating with key business functions to ensure accuracy and resolve discrepancies.

The role involves handling customer inquiries, applying guidelines, and ensuring compliance. Anticipated weekly hours are 40, with a comprehensive benefits package and eligibility for bonus programs.