Medicare Supplement Large Loss, Complex Claims Reinsurance Specialist

Role Description

The Medicare Supplement Complex Claims Reinsurance Specialist is responsible for adjudicating high‑value and complex Medicare Supplement claims, conducting reinsurance audits, and serving as a subject‑matter expert on risk management practices. This role ensures accurate claim determinations, protects organizational financial integrity, and strengthens operational excellence through training and process improvement.

Key Responsibilities

• Large‑Loss, Complex Claims Adjudication
  • Review, investigate, and adjudicate high‑dollar Medicare Supplement claims with accuracy, timeliness, and full regulatory compliance.
  • Analyze medical records, provider documentation, and policy provisions to determine eligibility and benefit levels.
  • Collaborate with internal teams, medical consultants, and external constituents to resolve complex claim issues.
  • Identify potential claim vulnerabilities that may involve fraud, waste, or abuse and escalate appropriately.
• Reinsurance and Audit Functions
  • Perform detailed reinsurance due diligence efforts audits to validate claim accuracy, recover eligible reimbursements, and ensure adherence to treaty requirements.
  • Prepare audit reports, document findings, and recommend corrective actions to improve financial outcomes.
  • Serve as a liaison with reinsurance clients, responding to inquiries and supporting periodic reviews.
• Risk Management and Training
  • Develop and deliver training programs for claims staff on risk identification, mitigation strategies, and best‑practice adjudication.
  • Provide coaching and guidance to enhance team competency in handling complex or high‑risk claims.
  • Monitor and reporting against emerging trends, regulatory changes, and operational risks, recommending updates to policies and workflows.

Role Qualifications and Experience

• Experience adjudicating Medicare Supplement or health insurance claims, with strong knowledge of CMS guidelines and supplemental benefits.
• Demonstrated expertise in large‑loss or complex claim review.
• Experience conducting reinsurance audits or working with reinsurance treaties preferred.
• Strong analytical, investigative, reporting and documentation skills.
• Ability to communicate complex concepts clearly to both technical and non‑technical audiences.
• Skilled at presenting information, training teams, and writing clear reports.
• Proven ability to train, mentor, or lead others in a claims or risk‑focused environment.
• Deep understanding of Medicare Supplement policies and claims processes.
• Ability to identify and analyze financial, operational, and compliance risks.
• Strong judgment in complex claim scenarios.
• Works effectively across departments and with external partners.
• Advanced proficiency in Power BI, Excel, and adept with AI enabled reporting and automation tools to automate insights and optimize dashboard efficiency.
• Flexibility to travel as required.

Pay

Salary Range: $91,000.00 - $152,000.00 USD

Contact Information

General Reinsurance Corporation
400 Atlantic Street, 9th Floor
Stamford, CT 06901 (US)
(US)