Senior Auditor, Stoploss Claim

Role Overview

• Audit and authorize reimbursement of specific medical stop loss claims
• Effectively mitigate client medical stop loss claims
• Provide excellent customer service
• Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier
• Recognize cost mitigation opportunities
• Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits
• Initiate claims investigations and vendor referrals
• Interpret plan language, and identify experimental services and subrogation opportunities
• Identify need for follow-up on pended claims and resolution
• Communicate effectively with carriers, vendors, and management
• Provide full claims service to both phone and written inquiries
• Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history
• Develop new and review old stop loss claim forms
• Assist with internal auditing of claims auditors, and training of claims auditors

Requirements

• Associate's degree
• 6 years of managed care or reinsurance claims experience
• Analyzes laws, regulations and contract language
• Evaluates issues and develops recommendations
• Handles confidential and sensitive information
• Investigates assigned claims
• Proposes claims adjustments and refunds
• Works claims caseloads
• Aggregate claims experience

Benefits

• Subsidized health plans
• Dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more