Senior Reinsurance & Stoploss Claims Adjudicator

CVS Health; Alton (IL); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Retirement savings options

Paid time off

Job summary

CVS Health is seeking a full-time Reinsurance/Stoploss Claims Adjuster to review and adjust complex medical claims in a high-volume environment. You will apply medical necessity guidelines, verify eligibility, and resolve discrepancies while collaborating with multiple business functions to ensure accurate pricing and payment handling.

The role requires 2+ years in medical claim processing and experience in a production setting, with a focus on complex claim adjudication and provider contract

Qualifications

• 2+ years medical claim processing experience.
• 2+ years in a production environment.
• Familiarity with Reinsurance/Stop loss medical claims is a plus.
• Strong communication, organizational and problem-solving skills.

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims across all dollar amounts.
• Collaborate with key business functions to ensure accuracy in claim adjustments.
• Handle customer inquiries related to pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Manage external correspondence and perform required adjustments to medical claims.
• Deliver training or mentor less-experienced team members when needed.
• Ensure compliance with company practices and procedures.

Skills

Medical claim processing

Education

Associate degree

Job description

CVS Health is seeking a full-time Reinsurance/Stoploss Claims Adjuster to review and adjust complex medical claims in a high-volume environment. You will apply medical necessity guidelines, verify eligibility, and resolve discrepancies while collaborating with multiple business functions to ensure accurate pricing and payment handling.

The role requires 2+ years in medical claim processing and experience in a production setting, with a focus on complex claim adjudication and provider contract