Strategic Reinsurance Claims Specialist (Stoploss)

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

Job summary

CVS Health is seeking a claims professional to review and adjudicate Reinsurance/Stoploss medical claims, including large and complex cases. You will apply medical necessity guidelines, verify eligibility, and resolve discrepancies while supporting internal partners across functions.

The role emphasizes accurate claim adjustments, timely customer responses, and adherence to policy language. A background in claims processing and collaboration within teams is essential for success.

Qualifications

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

Responsibilities

• Review and adjust Reinsurance/Stoploss medical claims across all dollar levels.
• Apply medical necessity guidelines and determine coverage.
• Handle customer inquiries related to claims.
• Rework calculations and reconcile discrepancies.
• Collaborate with business functions on pricing and payments.
• Mentor less experienced team members.

Skills

Medical claim processing

Production environment

Education

Associate degree or equivalent experience

Job description

CVS Health is seeking a claims professional to review and adjudicate Reinsurance/Stoploss medical claims, including large and complex cases. You will apply medical necessity guidelines, verify eligibility, and resolve discrepancies while supporting internal partners across functions.

The role emphasizes accurate claim adjustments, timely customer responses, and adherence to policy language. A background in claims processing and collaboration within teams is essential for success.