Reinsurance/Stoploss Medical Claims Adjuster

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At CVS Health, you'll be surrounded by colleagues who care deeply, innovate with purpose, hold themselves accountable and prioritize safety and quality in everything they do.

Job Summary Review, research, and adjust complex Reinsurance/Stoploss medical claims. Collaborate with key business functions to ensure accuracy in Reinsurance/Stoploss medical claim adjustments, problem-solve, and reconcile rework discrepancies. Handle customer inquiries and concerns.

Responsibilities

• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amount levels using technical and claims processing expertise.
• Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply cost containment measures.
• Conduct Reinsurance/Stoploss medical claim re-work calculations.
• Research and determine Reinsurance/Stoploss plan year, identify claim payments made by client versus Stoploss carriers, and interpret complex plan language.
• Follow through completion of Reinsurance/Stoploss medical claim overpayments, underpayments, and irregularities.
• Review and interpret medical contract language using provider contracts to confirm whether a Reinsurance/Stoploss claim is overpaid.
• Partner with key business functions to ensure accuracy in pricing, payment, and handling of complex Reinsurance/Stoploss claim adjustments.
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensure compliance requirements are satisfied and payments are made following company practices and procedures.
• Manage external correspondence assigned to the Adjustments department.
• May deliver Reinsurance/Stoploss claims adjustment training and/or serve as a mentor.

Requirements

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

Preferred Qualifications

• 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.

Education

• Associate degree or equivalent experience.

Benefits This full-time position is eligible for a comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources.

Pay Range $18.50 - $42.35 per hour