Acts as a liaison and subject matter expert between our internal and external clients and the stop loss administrators. Reviews and manages stop loss claim filings. Resolves discrepancies between the amount requested and the amount reimbursed by the stop loss carrier.
Fundamental Components and Physical Requirements include but are not limited to:
- Acts as principal point of contact for stop loss administrators
- Review and investigate inquiries from stop loss administrators
- Manage and/or request retro pre-cert reviews, medical necessity inquiries, medical records & physician orders, etc.
- Utilize all applicable system functions and department relationships to finalize stop loss filings
- Review, adjudicate and appeal as necessary mismatched stop loss reimbursements
- Use system reporting tools to maintain and manage daily work flow
- Maintaining good relationships with internal and external clients
- Ability to work independently and maintain service standards
- Technical and Analytical skills
- Proficiency in oral and written communications
Experience with medical claim processing
Experience with the DG claim system
High School or GED equivalent
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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