Senior Reinsurance & Stop-Loss Claims Adjuster

CVS Health; Illinois; On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Bonus eligibility

Comprehensive benefits package

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims across dollar levels. You will apply guidelines, determine coverage, verify eligibility, and collaborate with teams to ensure accurate adjudication and timely resolutions.

The role involves handling high-dollar, sensitive claims, performing re-work calculations, addressing overpayments/underpayments, and supporting training for junior staff.

Qualifications

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

Responsibilities

• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amounts.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification.
• 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.
• May deliver Reinsurance/Stoploss claims adjustment training and/or serve as a mentor for less experienced team members.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Tools

DG system claims processing

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims across dollar levels. You will apply guidelines, determine coverage, verify eligibility, and collaborate with teams to ensure accurate adjudication and timely resolutions.

The role involves handling high-dollar, sensitive claims, performing re-work calculations, addressing overpayments/underpayments, and supporting training for junior staff.