Stop Loss Claims Auditor

Responsibilities

• Demonstrate above average technical knowledge of all aspects of the stop loss process, specifically the claims review process
• Monitor claims inbox and respond, in a timely fashion, to all incoming claims
• Compile and review all claims information including employer health plans, stop loss insurance contracts, provider documentation, and all other claim evidence
• Audit submitted claims for sufficient data, verifying that benefits are paid correctly and in accordance with appropriate plans and policies
• Prepare written rationale of claim decisions based on review of appropriate evidence, contracts, etc.
• Set claim reserves and adjust as needed
• Enters appropriate stop loss claims and violations into designated database
• Identifies, researches, and resolves stop loss carrier questions or issues
• Facilitates advance funding with Finance Department
• Complies with reporting and documentation requirements
• Captures and tracks stop loss violation
• Manages large case notification process
• Manages various reporting requirements
• Notifies claims team and/or underwriting staff of newly disclosed claimants or extremely high-risk claimants after review of incoming precertification's and reports

Qualifications

• Associate or Bachelor's Degree or combination of experience and education
• 3-5 years of processing first dollar medical claims
• Processing Stop Loss Claims experience
• Prior experience in self-insured plan management
• Prior experience in Stop Loss Claims and Stop Loss industry

Skills and Abilities

• Strong communication (telephonic, oral, and written), interpersonal relationship, analytical and problem-solving skills as well as detail oriented
• Working knowledge of computers and software including but not limited to Microsoft Office products
• Demonstrated ability to work independently, prioritize workloads, multi-task and manage priorities in order to meet deadlines
• Knowledge of legal risks and regulatory/statutory guidelines of HIPPA, privacy, Patient Protection and Affordable Care Act, etc.
• Knowledge of Medical Terminology, CPT (Current Procedural Terminology), and International Classifications of Diseases (ICD-10)

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

Want to see our latest job opportunities?

Follow us on LinkedIn

About the role

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Schedule

Part of the Stop Loss Department

Benefits

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives