Senior Auditor, Stoploss Claim
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Job Description
Auditor handling medical stop loss claims for BlueCross BlueShield. Analyzing reimbursement and mitigating claims while providing excellent customer service.
Responsibilities:
- Audit and authorize reimbursement of specific medical stop loss claims.
- Effectively mitigate client medical stop loss claims and provide excellent customer service.
- Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier.
- Recognize cost mitigation opportunities.
- Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits.
- Initiate claims investigations and vendor referrals.
- Interpret plan language, and identify experimental services and subrogation opportunities.
- Identify need for follow-up on pended claims and resolution.
- Communicate effectively with carriers, vendors, and management.
- Provide full claims service to both phone and written inquiries.
- Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
- Develop new and review old stop loss claim forms.
- Assist with internal auditing of claims auditors, and training of claims auditors.
Requirements:
- Required Education: Associate's
- Required Work Experience: 6 years of managed care or reinsurance claims experience.
- Preferred Skills and Abilities: Analyzes laws, regulations and contract language.
- Evaluates issues and develops recommendations.
- Handles confidential and sensitive information.
- Investigates assigned claims.
- Proposes claims adjustments and refunds.
- Works claims caseloads.
- Aggregate claims experience.
Benefits:
- Subsidized health plans
- Dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
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