Stop Loss Examiner

• *About the role**

In this role, you will audit individual stop loss claim submissions through analysis of policy provisions, employer plan documents, administrative agreements, and cost containment vendor agreements to process accurate claim reimbursements made payable to the policyholder. You will also, review potential claim notices and submissions for cost containment opportunities.? *What you will do**
• Audit and make reimbursement determinations of stop loss claims in accordance with the provisions of the Policyholder's Plan Document and Stop Loss Policy
• Adjudicate claim reimbursements within established turnaround goals
• Maintain quality on claim procedures and financial accuracy with appropriate documentation
• Handle pending claims with consistent follow up, documentation, and resolution or closure within defined timeframes
• Interact with third party administrators and other contacts to obtain information needed to make reimbursement decision
• Provide prompt turnaround when information is received for reimbursement or denial
• Review advance notices of potential claims to identify and refer cases expected to become excess loss claims
• Alert MRC's, RGMs, and Underwriters of potential catastrophic claims risk as well as unusual and complex claim issues
• Interact with internal and external customers; respond to inquiries, handle appeals, facilitate claim resolutions, and provide and obtain education in industry claim treads and cost containment solutions
• Special projects as identified by management

Salary Range: $23.92-39.85/hr plus eligibility for annual bonus program? *Your experience and skills**
• High School Diploma required; college degree preferred
• 1-3 years of first dollar medical claims paying experience or medical insurance related experience is required
• Prior Stop Loss claims and catastrophic claim experience preferred
• Knowledge of the fundamental concepts of group health insurance, ERISA, employee benefit plans and reinsurance
• Proficient in medical terminology, use of ICD-10 and CPT coding, UB92 identifiers and HCFA forms
• Strong analytical and contract interpretation skills
• Experience with Microsoft Office Suite and intermediate Excel skills required
• ESL ? Stop Loss/Young Consulting System experience a plus
• Strong verbal and written communication skills
• Adept analytical, technical, and problem-solving skills
• Objective decision-making skills
• Able to work within timeframes and adapt to changes in priorities
• Self-motivated and driven
• Phenomenal at relationship building

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