Reinsurance/Stoploss Medical Claims Adjustor

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

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

Review, research, and adjust complex Reinsurance/Stoploss medical claims, splitting claims into multiple claim statuses; adjudicates high-dollar complex, sensitive, and/or specialized medical claims in accordance with claim processing guidelines. Collaborate and partner with key business functions to ensure accuracy in Reinsurance/Stoploss medical claim adjustments, problem-solve, and reconcile rework discrepancies. Handle customer inquiries and concerns.

• 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.

Required Qualifications

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

Preferred Qualifications

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

Education

• Associate degree or equivalent experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$18.50 - $42.35

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 11/04/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.