Stop Loss Claim Auditor

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

📋 Description

• Review and audit stop loss reimbursement requests to ensure accurate and timely payments.

• Assess claim and eligibility documentation while performing aggregate claim calculations within the assigned authority.

• Retrieve, log, organize, and review stop loss claim submissions along with their supporting documentation.

• Audit initial and supplemental reimbursement requests for eligibility, covered expenses, contract terms, deductible application, and plan or policy provisions.

• Conduct preliminary calculations and audits for aggregate accommodations and final year-end aggregate claim submissions.

• Identify discrepancies, exceptions, unclear contract language, and issues outside the delegated authority, escalating them as needed.

• Obtain and assess eligibility, extension-of-benefits, FMLA, COBRA, precertification, accident, subrogation, UB-04, itemized bills, and other supporting documents.

• Maintain comprehensive and accurate audit documentation, calculations, determinations, and supporting records within claim systems.

• Review plan documents, Summary Plan Descriptions, amendments, and related materials using checklists and approved automated or AI-assisted tools.

• Validate outputs from automated and AI-assisted reviews before applying them to claim or plan-document decisions.

• Identify issues related to eligibility, coordination, cost containment, payment integrity, and reimbursement, coordinating with both internal and external partners.

• Assist in monitoring high-cost claims, reserve and notification reviews, and related reporting activities.

• Communicate with TPAs, brokers, carriers, auditors, vendors, and internal partners regarding documentation, claim status, findings, and inquiries.

• Support claims quality reviews, reporting, research, procedure documentation, and continuous improvement initiatives.

• Provide backup assistance for claims intake and workflow tasks.

• Carry out responsibilities in accordance with procedures, contractual obligations, delegated authority, confidentiality standards, and regulatory requirements.

⛳️ Requirements

• A minimum of 3 years of experience in healthcare claims, stop loss claims, medical claim auditing, TPA operations, or a related field.

• Knowledge of self-funded medical plans, employer stop loss terminology, reimbursement processes, contracts, and operational workflows.

• Ability to interpret plan documents, stop loss policies, eligibility information, and claim documentation effectively.

• Strong analytical and mathematical skills for conducting detailed claim audits and reimbursement calculations.

• High attention to detail with the ability to maintain complete, accurate, and audit-ready documentation.

• Capacity to independently review claims within established procedures and delegated authority, escalating exceptions or high-risk matters as necessary.

• Excellent organizational and time-management abilities.

• Strong written and verbal communication skills.

• Proficiency in Microsoft Office applications, including Excel and Word.

• Willingness to learn stop loss administration, underwriting, and reporting systems.

• Ability to responsibly use approved automated and AI-assisted tools, ensuring human review and validation.

• Capability to handle confidential financial, claim, and member information with discretion.

• Must be based in the US and comply with company policies such as HIPAA.

• A Bachelor's degree in Healthcare Administration, Accounting, Finance, Insurance, Business, or a related field is preferred.

• Experience in auditing complex or high-dollar medical claims is an advantage.

• Familiarity with reviewing Summary Plan Descriptions, plan documents, stop loss contracts, or amendments is a plus.

• Experience with aggregate accommodation and year-end aggregate claim calculations is beneficial.

• Background with self-funded employers, stop loss carriers, TPAs, managing general underwriters, or related healthcare financing organizations is a plus.

• Experience in identifying payment integrity, cost containment, subrogation, coordination of benefits, or eligibility issues is advantageous.

• Knowledge of stop loss claims administration, underwriting, or reporting platforms is a plus.

🏝️ Benefits

• Competitive compensation aligned with experience and performance.

• Comprehensive benefits package featuring generous employer subsidies.

• Flexible and remote working arrangements.

• 401(k) plan with generous employer matching and immediate vesting.

• Opportunities for personal and professional development.

• Supportive family benefits, including paid leave for new family members.

• Companywide philanthropic program, Valenz Communities Connection.

• Necessary equipment provided for fully remote work.

• Generous subsidies on company-sponsored Medical, Dental, and Vision insurance.

• Access to Healthcare Blue Book and KISx Card services.

• Options for HSA, FSA, and DCFSA spending accounts.

• Flexible working environment.

• Generous paid time off, including vacation, sick leave, and paid holidays.

• Employee Assistance Program offering professional counseling, referrals, and additional services.

• Paid maternity and paternity leave.

• Pet insurance available.

• Employee discounts on phone plans, car rentals, and computers.

• Opportunities for community giveback, including paid time off for philanthropic activities.