Senior Reinsurance & Stop-Loss Claims Specialist

CVS Health; Virginia; Presencial; USD 25.000 - 58.000; Jornada completa

Descripción de la vacante

CVS Health is seeking a skilled Adjuster to review and adjust complex Reinsurance/Stoploss medical claims, ensuring accurate adjudication and alignment with contract terms. You will collaborate with cross-functional teams, apply medical necessity guidelines, and resolve discrepancies while supporting customer inquiries.

The role emphasizes attention to detail, compliance, and training others as needed, with a focus on high-dollar claims in a demanding healthcare environment.

Formación

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

Responsabilidades

• Review, adjust complex Reinsurance/Stoploss medical claims across dollar amounts.
• Apply medical necessity guidelines and determine coverage.
• Handle customer inquiries and concerns.
• Research plan year and interpret plan language for accurate adjustments.
• Follow through on overpayments and underpayments.
• Mentor less experienced team members.

Conocimientos

Medical claims processing

Production environment

Educación

Associate degree or equivalent experience

Descripción del empleo

CVS Health is seeking a skilled Adjuster to review and adjust complex Reinsurance/Stoploss medical claims, ensuring accurate adjudication and alignment with contract terms. You will collaborate with cross-functional teams, apply medical necessity guidelines, and resolve discrepancies while supporting customer inquiries.

The role emphasizes attention to detail, compliance, and training others as needed, with a focus on high-dollar claims in a demanding healthcare environment.