Claims Auditor – Stop Loss, Aggregate
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Job Description
Claims Auditor for validating medical stop loss aggregate claim reimbursements at Skyward Specialty. Ensuring accuracy and compliance through auditing claim data, eligibility, plan provisions, and contract terms.
Responsibilities:
- Review and validate medical stop loss aggregate claim reimbursements by auditing claim data, eligibility, plan provisions, and contract terms
- Audit aggregate stop loss submissions (weekly/monthly/quarterly/annual) to confirm accuracy
- Confirm appropriate treatment of: Coordination of Benefits (COB), subrogation, third-party recovery offsets, Provider credits/refunds, Rx rebates (if contractually relevant)
- Reconcile eligibility/enrollment counts
- Review Plan & Contract Interpret - Stop loss policy/certificate, endorsements, and amendments
- Communicate with underwriting, TPA’s, brokers/producers to resolve discrepancies
Requirements:
- 2+ years of experience of Stop loss Aggregate claim handling
- Working knowledge of: Aggregate stop loss concepts (attachment points, factors, contract basis, reimbursements), Medical claims components (allowed vs. paid, reversals/adjustments, claim timing), Eligibility/enrollment reconciliation
- Funding verification
- Strong analytical skills with attention to detail and ability to interpret plan/contract language
- Proficiency with Excel (pivot tables, XLOOKUP/VLOOKUP, filtering, data validation; comfort with large datasets)
Benefits:
- Health and welfare benefits
- Tuition and professional certification assistance
- 401k savings
- Elective participation in the Employee Stock Purchase Program
- Paid time off
- Paid holidays
- Child bonding leave
- Other employee assistance
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