Reinsurance & Stoploss Medical Claims Specialist

CVS Health; Hartford (CT); On-site; USD 21,000 - 30,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health in Hartford, CT is seeking an experienced Reinsurance/Stoploss claims adjuster to review, research, and adjust complex medical claims while collaborating with key business functions to ensure accuracy and timely resolution. You will adjudicate high-dollar claims, apply medical necessity guidelines, manage overpayments/underpayments, respond to customer inquiries, and mentor teammates.

An Associate degree or equivalent experience is preferred, with 40 hours weekly and a comprehensive

Qualifications

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

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Collaborate with key business functions to ensure accuracy in claim adjustments.
• Handle customer inquiries and concerns related to claims.
• Perform adjustments across all dollar levels using claims processing expertise.
• Apply medical necessity guidelines and verify eligibility.
• Identify discrepancies and apply cost containment measures.
• Re-work calculations for Stoploss/ Reinsurance claims.
• Review contract language and provider contracts for overpayments.
• Mentor less experienced team members and deliver training as needed.
• Manage external correspondence and triage actions affecting claims.
• Ensure compliance and proper payment procedures.
• Support pre-approvals/pre-authorizations, reconsiderations, or appeals.

Skills

Medical claim processing

Production environment

Education

Associate degree or equivalent experience

Job description

CVS Health in Hartford, CT is seeking an experienced Reinsurance/Stoploss claims adjuster to review, research, and adjust complex medical claims while collaborating with key business functions to ensure accuracy and timely resolution. You will adjudicate high-dollar claims, apply medical necessity guidelines, manage overpayments/underpayments, respond to customer inquiries, and mentor teammates.

An Associate degree or equivalent experience is preferred, with 40 hours weekly and a comprehensive