Senior Stop Loss Claims Auditor

This is a fully remote position, open to applicants in South Carolina.

📋 Description

• Audit and authorize reimbursements for specific medical stop loss claims.

• Mitigate client medical stop loss claims while providing excellent customer service.

• Analyze and adjudicate stop loss claims and request appropriate reimbursements from carriers.

• Identify opportunities for cost mitigation.

• Authorize and issue reimbursement checks within predetermined authority limits.

• Initiate investigations into claims and make vendor referrals as necessary.

• Interpret plan language to identify experimental services and subrogation opportunities.

• Follow up on pending claims and resolve any outstanding issues.

• Communicate effectively with carriers, vendors, and management.

• Provide claims services for both phone and written inquiries.

• Generate and maintain reports in the claims system to adjust reserves and identify pending and backlog claims.

• Provide history regarding renewals and enrollment/premiums.

• Develop new and review existing stop loss claim forms.

• Assist in internal auditing and training of claims auditors.

⛳️ Requirements

• Associate's Degree.

• 2 years of job-related work experience may be accepted as an equivalency for the Associate's Degree.

• 6 years of experience in managed care or reinsurance claims.

• Ability to analyze laws, regulations, and contract language.

• Skill in evaluating issues and developing recommendations.

• Proficient in handling confidential and sensitive information.

• Ability to investigate assigned claims thoroughly.

• Capable of proposing claims adjustments and refunds.

• Experience managing claims caseloads.

• Experience aggregating claims data.

🏝️ 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 for movies, theaters, zoos, theme parks, and more.

• Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs.

• Pay differential coverage for full-time employees in the National Guard or Reserves called to active duty.