Senior Reinsurance & Stoploss Medical Claims Adjuster

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

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health is looking for an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will collaborate with key business functions to ensure accurate adjustments and respond to customer inquiries.

The role involves applying medical necessity guidelines, eligibility verification, and cost containment measures across all claim levels. 40-hour work week in Texas with a focus on accuracy, problem-solving, and supporting the team in managing

Qualifications

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

Responsibilities

• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the Reinsurance/Stoploss claim adjudication process.
• Performs Reinsurance/Stoploss medical claim re-work calculations.
• Research and determine Reinsurance/Stoploss plan year, identify claim payments made by client versus the Stoploss carriers, and interpret complex plan language to ensure accurate handling of complex adjustments.
• Follow through completion of Reinsurance/Stoploss medical claim overpayments, underpayments, and any other irregularities.
• Review and interpret medical contract language using provider contracts to confirm whether a Reinsurance/Stoploss claim is overpaid to allocate refund checks.
• Partner with key business functions to ensure accuracy in pricing, payment, and handling of complex Reinsurance/Stoploss claim adjustments.
• Review and handle relevant correspondences assigned to the team that may result in adjustment to Reinsurance/Stoploss medical claims.
• 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.
• Manage external correspondence assigned to the Adjustments department; research, triage, and perform required actions, including adjustments to medical claims.
• May deliver Reinsurance/Stoploss claims adjustment training and/or serve as a mentor for less experienced team members.
• May provide job shadowing to lesser experience staff.
• Utilize all resource materials to manage job responsibilities.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Job description

CVS Health is looking for an experienced Reinsurance/Stoploss Claims Adjuster to review, research, and adjust complex medical claims. You will collaborate with key business functions to ensure accurate adjustments and respond to customer inquiries.

The role involves applying medical necessity guidelines, eligibility verification, and cost containment measures across all claim levels. 40-hour work week in Texas with a focus on accuracy, problem-solving, and supporting the team in managing