Senior Reinsurance & Stoploss Claims Specialist

CVS Health; Yuma (AZ); On-site; USD 25,000 - 58,000; Full time

Job summary

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research and adjust complex medical claims. You will split claims into statuses, apply medical necessity guidelines, determine coverage, and handle inquiries.

Responsibilities include claim adjustments, working with pricing and payments teams, and mentoring junior staff. This full-time role offers a comprehensive benefits package and opportunities for professional growth within CVS Health.

Qualifications

• 2+ years of medical claim processing experience.
• 2+ experience in a production environment.
• 2+ years processing medical claims adjustments/rework.
• DG system claims processing experience.
• Familiarity with Reinsurance/Stop loss medical claims.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communications, organizational, and interpersonal skills.
• Associate degree or equivalent experience.

Responsibilities

• Review, research, and adjust complex Reinsurance/Stoploss medical claims across all dollar amounts.
• Collaborate with key business functions to ensure accuracy in pricing, payment and handling of adjustments.
• Handle customer inquiries related to pre-approvals/pre-authorizations, reconsiderations or appeals.
• Perform Reinsurance/Stoploss claim adjustments and re-work calculations.
• Review contract language to confirm overpayments and allocate refunds.
• Mentor less experienced team members and provide job shadowing as needed.

Skills

Medical claim processing

Education

Associate degree or equivalent experience

Job description

CVS Health is seeking a Reinsurance/Stoploss Claims Adjuster to review, research and adjust complex medical claims. You will split claims into statuses, apply medical necessity guidelines, determine coverage, and handle inquiries.

Responsibilities include claim adjustments, working with pricing and payments teams, and mentoring junior staff. This full-time role offers a comprehensive benefits package and opportunities for professional growth within CVS Health.