Reinsurance/Stoploss Medical Claims Adjustor

This is a fully remote position, open to applicants in Alabama, +39 more states.

📋 Description

• Conduct reviews, research, and adjustments for complex Reinsurance/Stoploss medical claims.

• Segment claims into various claim statuses.

• Adjudicate high-value, intricate, sensitive, and specialized medical claims in accordance with processing protocols.

• Collaborate with business units to ensure precision and resolve rework discrepancies.

• Address customer inquiries and concerns effectively.

• Implement medical necessity guidelines to ascertain coverage.

• Carry out eligibility verifications and identify any discrepancies.

• Enforce cost containment strategies during the claim adjudication process.

• Execute claims re-work calculations.

• Investigate plan years and differentiate client payments from Stoploss carrier payments.

• Interpret complex language found in plans and medical contracts.

• Resolve issues related to overpayments, underpayments, and other irregularities.

• Manage correspondence, pre-approval/pre-authorization requests, reconsiderations, and appeals.

• Ensure compliance and facilitate accurate payments.

• Research, triage, and respond to external correspondence.

• Provide claims adjustment training, mentor less experienced team members, and offer job shadowing as needed.

⛳️ Requirements

• A minimum of 2 years of experience in medical claim processing.

• At least 2 years of experience working in a production environment.

• An Associate degree or equivalent experience is required.

• Over 2 years of experience in processing medical claims adjustments/rework.

• Experience with DG system claims processing.

• Familiarity with Reinsurance/Stoploss medical claims is preferred.

• Capability to manage multiple assignments competently, accurately, and efficiently.

• Strong communication, organizational, and interpersonal skills are essential.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.