Stop Loss Claims Auditor

Responsibilities

• Perform quality review and evaluation of all claim submissions received and logged into our claims system to determine whether the amount requested is eligible for reimbursement.
• Maintain a processing accuracy of 99% or better.
• Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim.
• Review and adjudicate claims within approved authority limits.
• Maintain assigned claim block and assist other team members while meeting departmental guidelines.
• Document rationale of claim decisions based on review of the contractual provisions, plan specifications and the analysis of medical records, etc.
• Elevate issues to next level of supervision, as appropriate.

Requirements

• 3-5+ years stop loss claims experience.
• Prior experience handling first dollar payer insurance (medical healthcare claims).
• Experience with medical billing practices, CPT codes, revenue codes, and/or universal billing.
• Able to use mathematics to adjudicate claims.
• Detail oriented with a high degree of accuracy and ability to multitask.
• Strong problem solving, decision-making, reporting and analytical skills.
• Must possess good judgment and work effectively with internal business areas, peers and co-workers.
• Demonstrated proficiency in Microsoft Office software.

Qualifications

• What you need to have:
• 3-5+ years stop loss claims experience.
• Prior experience handling first dollar payer insurance (medical healthcare claims).
• Experience with medical billing practices, CPT codes, revenue codes, and/or universal billing.
• Able to use mathematics to adjudicate claims.
• Detail oriented with a high degree of accuracy and ability to multitask.
• Strong problem solving, decision-making, reporting and analytical skills.
• Must possess good judgment and work effectively with internal business areas, peers and co-workers.
• Demonstrated proficiency in Microsoft Office software.

Skills

• Ability to handle stop loss claims at the reinsurance level (medical healthcare claims).
• Ability to work independently, prioritize, organize and assign own work to meet deadlines.
• Ability to accept changing priorities with a minimum of disruption.

Benefits

• Competitive compensation plan.
• Robust benefits package for full time regular employees including: Base Salary Range: $70,000 - $80,000.
• Health, dental, vision, dental, life, disability, wellness, paid time off, 401(k) and generous profit-sharing plan.