Claims Auditor, Stop Loss - Aggregate

Key Responsibilities

• Audit aggregate stop loss submissions to confirm accuracy of: Paid claims, Contract basis, Attachment point, Aggregate deductible.
• Confirm appropriate treatment of: Coordination of Benefits (COB), subrogation, third-party recovery offsets, Provider credits/refunds, Rx rebates (if contractually relevant), and overpayment recoveries.
• Identify discrepancies in eligibility files (late adds/terms, dependent status issues, retro changes).
• Review Plan & Contract Interpret - Stop loss policy/certificate, endorsements, and amendments, Administrative Services Agreement (ASA) where relevant, Plan documents/SPDs and claim payment policies.
• Communicate with underwriting, TPA’s, brokers/producers to resolve discrepancies in banking transactions, funding or any other claim issues.

Required Qualifications

• 2+ years of experience of Stop loss Aggregate claim handling.
• Working knowledge of: Aggregate stop loss concepts (attachment points, factors, contract basis, reimbursements), Medical claims components (allowed vs. paid, reversals/adjustments, claim timing), Eligibility/enrollment reconciliation. Funding verification.
• Strong analytical skills with attention to detail and ability to interpret plan/contract language.
• Proficiency with Excel (pivot tables, XLOOKUP/VLOOKUP, filtering, data validation; comfort with large datasets).

Pay

The applicable base salary for this opportunity is $65,000.00 - $85,000.00. The base pay offered will be determined by factors such as experience, skills, training, location, certifications, education, and any applicable minimum wage requirements. In addition to the base salary, this opportunity may be eligible for performance-based incentives.

Benefits

We are excited to offer a competitive total rewards package which includes health and welfare benefits, tuition and professional certification assistance, 401k savings, elective participation in the Employee Stock Purchase Program, paid time off, paid holidays, and child bonding leave, as well as other employee assistance.