Reinsurance/Stoploss Medical Claims Adjustor

About the role

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

Review, research, and adjust complex Reinsurance/Stoploss medical claims, splitting claims into multiple claim statuses; adjudicates high-dollar complex, sensitive, and/or specialized medical claims in accordance with claim processing guidelines. Collaborate and partner with key business functions to ensure accuracy in Reinsurance/Stoploss medical claim adjustments, problem-solve, and reconcile rework discrepancies. Handle customer inquiries and concerns.

• Perform Reinsurance/Stoploss medical claim adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the Reinsurance/Stoploss claim adjudication process.
• Performs Reinsurance/Stoploss medical claim re-work calculations.
• Research and determine Reinsurance/Stoploss plan year, identify claim payments made by client versus the Stoploss carriers, and interpret complex plan language to ensure accurate handling of complex adjustments.
• Follow through completion of Reinsurance/Stoploss medical claim overpayments, underpayments, and any other irregularities.
• Review and interpret medical contract language using provider contracts to confirm whether a Reinsurance/Stoploss claim is overpaid to allocate refund checks.
• Partner with key business functions to ensure accuracy in pricing, payment, and handling of complex Reinsurance/Stoploss claim adjustments.
• Review and handle relevant correspondences assigned to the team that may result in adjustment to Reinsurance/Stoploss medical claims.
• Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures.
• Manage external correspondence assigned to the Adjustments department; research, triage, and perform required actions, including adjustments to medical claims.
• May deliver Reinsurance/Stoploss claims adjustment training and/or serve as a mentor for less experienced team members.
• May provide job shadowing to lesser experience staff.
• Utilize all resource materials to manage job responsibilities.

Required Qualifications

• 2+ years medical claim processing experience.
• 2+ 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.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.