Strategic Reinsurance & Stoploss Claims Specialist

CVS Health; Central City (NE); On-site; USD 25,000 - 58,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement plan

Wellness programs

Job summary

CVS Health in Central City, Nebraska, is seeking a detail-oriented Reinsurance/Stoploss Claims Adjuster to review, adjust, and adjudicate high-dollar medical claims. You will collaborate with teams to ensure accurate claim adjustments, apply medical necessity guidelines, verify eligibility, and resolve discrepancies across complex plan language.

You will handle inquiries, support pre-authorizations and appeals, and may mentor junior staff.

Qualifications

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

Responsibilities

• Review, adjust complex Reinsurance/Stoploss medical claims across statuses.
• Collaborate with key functions to ensure accuracy in adjustments.
• Handle customer inquiries and concerns.
• Perform Reinsurance/Stoploss claim adjustments leveraging processing expertise.
• Apply medical necessity guidelines and determine coverage.
• Research plan year, verify payments, interpret plan language.
• Address overpayments/underpayments and irregularities.
• Review contract language to confirm overpayments.
• Support pricing, payment, and handling of complex adjustments.
• Handle correspondences leading to claim adjustments.
• Respond to requests for pre-authorizations and appeals.
• Ensure compliance with company practices.
• May train or mentor staff.
• May provide job shadowing.
• Utilize resource materials to manage responsibilities.

Skills

Medical claim processing

Production environment experience

Education

Associate degree or equivalent experience

Job description

CVS Health in Central City, Nebraska, is seeking a detail-oriented Reinsurance/Stoploss Claims Adjuster to review, adjust, and adjudicate high-dollar medical claims. You will collaborate with teams to ensure accurate claim adjustments, apply medical necessity guidelines, verify eligibility, and resolve discrepancies across complex plan language.

You will handle inquiries, support pre-authorizations and appeals, and may mentor junior staff.