Reinsurance/Stoploss Medical Claims Adjustor
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Job Description
Medical claims adjustor reviewing and adjudicating complex Reinsurance/Stoploss claims for CVS Health. Researching coverage, recalculating payments, resolving discrepancies, and handling appeals.
Responsibilities:
- Review, research, and adjust complex Reinsurance/Stoploss medical claims
- Split claims into multiple claim statuses
- Adjudicate high-dollar, complex, sensitive, and specialized medical claims according to processing guidelines
- Collaborate with business functions to ensure accuracy and reconcile rework discrepancies
- Handle customer inquiries and concerns
- Apply medical necessity guidelines and determine coverage
- Complete eligibility verification and identify discrepancies
- Apply cost containment measures during claim adjudication
- Perform claim re-work calculations
- Research plan years and distinguish client payments from Stoploss carrier payments
- Interpret complex plan and medical contract language
- Resolve overpayments, underpayments, and other irregularities
- Handle correspondence, pre-approval/pre-authorization requests, reconsiderations, and appeals
- Ensure compliance and accurate payments
- Research, triage, and act on external correspondence
- Deliver claims adjustment training, mentor less experienced team members, and provide job shadowing when needed
Requirements:
- 2+ years medical claim processing experience
- 2+ years experience in a production environment
- Associate degree or equivalent experience
- 2+ years processing medical claims adjustments/rework
- DG system claims processing experience
- Familiarity with Reinsurance/Stoploss medical claims
- Ability to handle multiple assignments competently, accurately, and efficiently
- Effective communication, organizational, and interpersonal skills
Benefits:
- CVS Health bonus, commission or short-term incentive program
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
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