Reinsurance & Stoploss Medical Claims Specialist

CVS Health; Denver (CO); 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

Bonus program

Job summary

CVS Health in Denver, CO is seeking a Reinsurance/Stoploss Claims Adjuster to review, research and adjust complex medical claims while collaborating with cross-functional teams to ensure accurate adjudication and customer service.

The role handles high-dollar adjustments, applies medical necessity guidelines, verifies eligibility, and analyzes plan language to resolve overpayments, underpayments, and reworks, with full-time hours and competitive benefits.

Qualifications

• 2+ years medical claim processing experience.
• 2+ years in a production environment.
• 2+ years processing medical claims adjustments/rework.
• Familiarity with Reinsurance/Stop loss medical claims.

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims across all dollar levels.
• Apply medical necessity guidelines and determine coverage and eligibility.
• Identify discrepancies and apply cost containment measures in adjudication.
• Research plan year, compare client payments with Stoploss carriers, and interpret plan language.
• Handle overpayments/underpayments and other irregularities.
• Review contract language to confirm overpayments and allocate refunds.
• Collaborate with pricing, payments, and adjustments to ensure accuracy.
• Handle inquiries related to pre-approvals, reconsiderations, or appeals.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Job description

CVS Health in Denver, CO is seeking a Reinsurance/Stoploss Claims Adjuster to review, research and adjust complex medical claims while collaborating with cross-functional teams to ensure accurate adjudication and customer service.

The role handles high-dollar adjustments, applies medical necessity guidelines, verifies eligibility, and analyzes plan language to resolve overpayments, underpayments, and reworks, with full-time hours and competitive benefits.