Reinsurance/Stoploss Medical Claims Adjustor

CVS Health • Washington, NV

3d • $19 - $42

About The Position

Review, research, and adjust complex Reinsurance/Stoploss medical claims, including splitting claims into multiple claim statuses and adjudicating high-dollar, sensitive, or specialized claims according to processing guidelines. Partner with key business functions to ensure accurate adjustments, resolve problems, and reconcile rework discrepancies. Handle customer inquiries and concerns.

Perform claim adjustments across all dollar amounts using customer service platforms and technical claims-processing expertise. Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and apply cost-containment measures. Calculate claim rework; research plan years and payments made by clients and Stoploss carriers; and interpret complex plan and provider contract language to ensure accurate adjustments and refund allocations.

Follow through on overpayments, underpayments, and other irregularities. Review relevant correspondence and manage external correspondence assigned to the Adjustments department, researching, triaging, and taking required action. Handle telephone and written inquiries related to pre-approvals, pre-authorizations, reconsiderations, and appeals. Ensure compliance requirements are met and payments follow company practices and procedures. May deliver claims adjustment training, mentor less experienced team members, or provide job shadowing. Use available resource materials to manage job responsibilities.

Requirements

• At least 2 years of medical claim processing experience.
• At least 2 years of experience in a production environment.
• Associate degree or equivalent experience.
• Demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
• Effective communication, organizational, and interpersonal skills.

Nice To Haves

• At least 2 years of experience processing medical claim adjustments or rework.
• DG system claims-processing experience.
• Familiarity with Reinsurance/Stoploss medical claims.

Responsibilities

• Review, research, adjust, and adjudicate complex Reinsurance/Stoploss medical claims according to claim-processing guidelines.
• Split claims into multiple claim statuses and process adjustments across all dollar amounts using customer service platforms.
• Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and apply cost-containment measures.
• Perform Reinsurance/Stoploss medical claim rework calculations.
• Research plan years and identify payments made by clients versus Stoploss carriers; interpret plan language to handle complex adjustments accurately.
• Follow through on claim overpayments, underpayments, and other irregularities.
• Review and interpret medical contract language and provider contracts to confirm overpayments and allocate refund checks.
• Partner with key business functions to ensure accurate pricing, payment, and handling of complex claim adjustments; resolve problems and reconcile rework discrepancies.
• Review relevant correspondence and manage external correspondence assigned to the Adjustments department, researching, triaging, and taking required action, including claim adjustments.
• Handle telephone and written inquiries concerning pre-approvals, pre-authorizations, reconsiderations, and appeals.
• Ensure compliance requirements are satisfied and payments follow company practices and procedures.
• May deliver claims-adjustment training, mentor less experienced team members, or provide job shadowing.
• Use resource materials to manage job responsibilities.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting colleagues' physical, emotional, and financial well-being, based on eligibility
• Eligible for a CVS Health bonus, commission, or short-term incentive program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree