Cost Containment Specialist

About the Role

The Cost Containment Specialist supports medical cost management across the A&H claims portfolio, with a focus on high-dollar and complex claims. This role reviews claim information, identifies potential savings opportunities, coordinates with claims teams, TPAs, and vendors, and helps ensure cost containment efforts are documented, tracked, and moved forward timely.

Responsibilities

• Review high-dollar and complex medical claims to identify cost drivers, savings opportunities, and appropriate next steps.
• Support claims teams by reviewing medical bills, clinical information, and claim documentation for potential cost containment opportunities.
• Coordinate with TPAs and external vendors, including bill review, clinical review, specialty networks, and other cost containment partners.
• Track assigned referrals, follow up on open items, and help ensure savings opportunities are moving forward timely.
• Document claim review findings, vendor recommendations, and cost containment outcomes clearly and consistently.
• Monitor claim activity and emerging medical cost trends that may impact large loss outcomes.
• Assist with reporting on savings, referral activity, claim status, and vendor results.
• Contribute to process improvements, tools, and best practices that support effective medical cost management.

Work Experience

Necessary:

• Experience in medical cost containment, complex claims review, medical billing, or Accident & Health claims support.
• Experience reviewing medical claims and identifying cost drivers, savings opportunities, or referral needs.

Preferred:

• Experience in medical stop loss, Accident & Health, or employer-sponsored health plans.
• Clinical, billing, coding, or claim review experience helpful but not required.
• Experience working with TPAs, bill review vendors, clinical review resources, or specialty cost containment solutions.

Qualifications

Necessary:

• Bachelor’s degree or equivalent combination of education and relevant work experience.
• Working knowledge of medical billing, coding, claim review, or cost containment practices.

Preferred:

• Registered Nurse (RN) or similar clinical credential.
• Experience in Accident & Health, medical stop loss, or employer-sponsored health plans.
• Understanding of medical claim review, large loss claims, and key medical cost drivers.

Pay

The salary range for this role is $98,500.00 - $185,000.00. The salary offer will be decided based on the role's complexity, its location, and the candidate’s professional background, including their education and experience.

Benefits

• Hybrid Working – a mix of working from home and in the office
• 22 weeks of paid leave for family growth, with 12 weeks available to all parents on a gender-equal basis
• Competitive 401(k) program with company match up to 8%
• Well-being program including holistic wellbeing coaching, gym membership, confidential counselling, financial and legal advice
• Tuition Reimbursement for professional certifications, and continuing education
• Employee Network and Community – QBE actively supports six Employee Networks, and many ways to give back to your community

Skills

• Administration Management
• Analytical Thinking
• Case Management
• Claims Management
• Communication
• Critical Thinking
• Customer Service
• Decision Making
• Health Care
• Intentional Collaboration
• Managing Performance
• Process Refinement
• Regulatory Compliance
• Risk Management
• Stakeholder Management