Senior Reinsurance & Stoploss Claims Adjuster

CVS Health; Idaho; In loco; USD 25.000 - 58.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement options

Descrizione del lavoro

CVS Health is seeking a professional to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will adjudicate high-dollar cases, collaborate with key business functions, and handle customer inquiries while ensuring accuracy and compliance with processing guidelines.

The role emphasizes applying medical necessity guidelines, verifying eligibility, and performing re-work calculations. A strong team-oriented approach will be essential to succeeding in a fast-paced

Competenze

• 2+ years medical claim processing experience.
• 2+ experience in a production environment.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communications, organizational, and interpersonal skills.

Mansioni

• Review, research, and adjust complex Reinsurance/Stoploss medical claims.
• Adjudicate high-dollar complex medical claims following guidelines.
• Collaborate with key functions to ensure accuracy in claim adjustments.
• Handle inquiries related to pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance and proper payments per company procedures.

Conoscenze

Medical claim processing

Production environment

Communication skills

Formazione

Associate degree or equivalent experience

Strumenti

DG system claims processing

Descrizione del lavoro

CVS Health is seeking a professional to review, research, and adjust complex Reinsurance/Stoploss medical claims. You will adjudicate high-dollar cases, collaborate with key business functions, and handle customer inquiries while ensuring accuracy and compliance with processing guidelines.

The role emphasizes applying medical necessity guidelines, verifying eligibility, and performing re-work calculations. A strong team-oriented approach will be essential to succeeding in a fast-paced