Senior Stoploss Claim Auditor

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

📋 Description

• Review and approve reimbursement requests for specific and/or aggregate medical stop loss claims.

• Effectively address client medical stop loss claims while delivering outstanding customer service.

• Analyze and process stop loss claims, requesting suitable reimbursement from the insurance carrier.

• Identify opportunities for cost mitigation.

• Authorize and issue reimbursement checks for stop loss claims within pre-established authority limits.

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

• Interpret plan language, pinpoint experimental services, and explore subrogation opportunities.

• Recognize the need for follow-up on pending claims and work towards resolution.

• Communicate efficiently with carriers, vendors, and management.

• Provide comprehensive claims service for both phone and written inquiries.

• Create and maintain reports in the claims system to adjust reserves, track pending and backlog claims, and document renewal and enrollment/premium history.

• Develop new stop loss claim forms and review existing ones.

• Support internal auditing processes of claims auditors and assist in their training.

⛳️ Requirements

• Required Education: Associate's degree.

• Required Work Experience: 6 years in managed care or reinsurance claims.

• Preferred Skills and Abilities: Ability to analyze laws, regulations, and contract language.

• Capable of evaluating issues and formulating recommendations.

• Proficient in handling confidential and sensitive information.

• Experienced in investigating assigned claims.

• Skilled in proposing claims adjustments and issuing refunds.

• Competent in managing claims caseloads.

• Experience with aggregate claims.

🏝️ 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.