Reinsurance/Stoploss Medical Claims Adjustor

CVS Health

. Review, research, and adjust complex Reinsurance/Stoploss medical claims .

Posted 10/23/2026full-timeRemote • United StatesJuniorMid-Level💰 $19 - $42 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claims processing, including adjudication of complex Reinsurance and Stoploss claims, while ensuring compliance and accuracy in payments. Proficient in delivering training and mentoring to enhance team capabilities.

Highest-signal resume keywords

Medical Claims ProcessingReinsurance/Stoploss ClaimsClaims Adjustment/ReworkEffective CommunicationOrganizational Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationEligibility VerificationCost Containment MeasuresClaim Re-work CalculationsMedical Necessity GuidelinesPlan Year ResearchComplex Contract InterpretationOverpayment ResolutionUnderpayment ResolutionClaims Processing Guidelines

Soft Skills

Interpersonal SkillsOrganizational SkillsEffective Communication

Tools & Technologies

DG System Claims Processing

Industry Keywords

Medical ClaimsReinsuranceStoplossClaims AdjustmentComplianceCustomer InquiriesPre-approval RequestsAppealsDiscrepancy IdentificationClaims Training

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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