Stop Loss Claims Analyst
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Job Description
Analyzing stop loss claims ensuring compliance with policy and contractual terms at Cambia. Collaborating with teams to improve claims processing and efficiency in Oregon and nearby states.
Responsibilities:
- Accurately apply contract benefits within guidelines and recognize incomplete or inappropriate claims.
- Recognize all policies and procedures that apply to claim and be able to quickly reference documentation for details.
- Make informed decisions regarding the disposition of claim; may include payment or denial of claim, or requests for further information.
- Lead the process to measure, track, and report all aggregate claims.
- Audit all aggregate claims onsite and off-site when needed based on set dollar threshold.
- Provide client audit reporting as needed.
- Manage inventory of claims while ensuring best practices and claim standards are met.
- Identify new opportunities to track and process claims more efficiently.
- Thoroughly document claims throughout the adjudication process so they can be understood by the team and for audit purposes.
- Analyze and investigate all claims, request supplementary documentation as necessary, in order to process or reprocess claims in a timely and accurate manner.
Requirements:
- Stop Loss Claims Analyst would have a/an High School Diploma or GED and 5 years of professional claims processing experience or equivalent combination of education and experience.
- Knowledge of when to utilize legal and clinical resources to comprehend legal and medical terminology in order to make final determinations on whether to approve or further investigate a claim.
- Possess strong knowledge of Policy and Contract terms, lasering, aggregating deductibles and eligibility to ensure correct processing of all eligible claim reimbursements.
- Advanced knowledge of claim reserving and settlement.
- Excellent communication skills for both external and internal customers
- Demonstrate understanding of medical terminology and ICD-10/CPT coding.
- Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.
Benefits:
- Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
- Annual employer contribution to a health savings account.
- Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
- Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
- Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
- Award-winning wellness programs that reward you for participation.
- Employee Assistance Fund for those in need.
- Commute and parking benefits.
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