Senior Stop Loss Claims Auditor

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

📋 Description

• Review and authorize reimbursement for designated medical stop loss claims.

• Reduce client medical stop loss claims while delivering exceptional customer service.

• Assess and adjudicate stop loss claims, requesting necessary reimbursements from carriers.

• Identify opportunities for cost mitigation.

• Approve and disburse stop loss claims reimbursement checks within authorized limits.

• Initiate investigations for claims and refer to vendors as needed.

• Interpret plan documentation, identifying experimental services and subrogation opportunities.

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

• Communicate effectively with carriers, vendors, and management.

• Provide claims support for both phone and written inquiries.

• Generate and maintain claims system reports to adjust reserves and identify outstanding and backlog claims.

• Supply renewal and enrollment/premium history information.

• Develop new and review existing stop loss claim forms.

• Assist with internal audits and training for claims auditors.

⛳️ Requirements

• An Associate's Degree is required.

• Two years of relevant work experience may be considered equivalent to the degree requirement.

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

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

• Evaluate issues and formulate recommendations.

• Handle confidential and sensitive information with discretion.

• Conduct investigations on assigned claims.

• Suggest claims adjustments and refunds as necessary.

• Manage claims caseloads effectively.

• Possess aggregated claims experience.

🏝️ Benefits

• Subsidized health plans, along with dental and vision coverage.

• A 401k retirement savings plan with company matching contributions.

• Life insurance coverage.

• Paid Time Off (PTO).

• On-site cafeterias and fitness centers available at major locations.

• Education assistance programs.

• Recognition for service milestones.

• National discounts for movies, theaters, zoos, theme parks, and more.