Reinsurance & Stoploss Medical Claims Specialist

CVS Health; Utah; 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

Job summary

CVS Health is seeking a detail‑oriented professional to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will split claims into statuses, adjudicate high-dollar cases, and collaborate with business functions to ensure accurate adjustments and compliance.

The role requires 2+ years in medical claim processing and a track record in production environments, with strong communication and organizational skills.

Qualifications

• Minimum 2 years of medical claim processing experience.
• Minimum 2 years in a production environment.
• Strong communication and interpersonal skills required.

Responsibilities

• Review complex Reinsurance/Stoploss medical claims and adjudicate based on guidelines.
• Adjust claims across dollar amounts and prepare rework calculations.
• Collaborate with internal teams to ensure accurate pricing, payments, and adjustments.
• Handle inquiries related to pre-approvals, reconsiderations, or appeals.
• Ensure compliance with company policies and regulatory requirements.
• Provide training or mentoring as needed to junior staff.

Skills

Medical claim processing

Production experience

Communication skills

Organizational skills

Interpersonal skills

Education

Associate degree or equivalent experience

Job description

CVS Health is seeking a detail‑oriented professional to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will split claims into statuses, adjudicate high-dollar cases, and collaborate with business functions to ensure accurate adjustments and compliance.

The role requires 2+ years in medical claim processing and a track record in production environments, with strong communication and organizational skills.