Reinsurance/Stoploss Medical Claims Adjustor

Job not on LinkedIn

🔥 3 minutes ago

🏈 Alabama, Alaska, +38 more states – Remote

🏈 Alabama – Remote 🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote 🧀 Wisconsin – Remote

💵 $18 - $42 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔒 Insurance

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• 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