Senior Claims Analyst

Position Overview

The Senior Claims Analyst is responsible for assisting the Director, Claims and Clinical. This individual will ensure that stop-loss claims are properly adjudicated in accordance with our Policy and the underlying plan/group Plan Documents. This role will focus on the details of each claim and the relationship between the BCS and the customers (Plans). In addition to tasks listed above, the Senior Claims Analyst is expected to have a working knowledge of procedures related to gathering accident & health insurance claim information, the identification of questionable charges, alerting the team of disputable expenses, confirming and retrieving overpayments, and the documentation of transactions.  

This position will report to the Director, Claims and Clinical. 


Essential Elements

• Claim Review- Review, analyze, manage, and adjudicate claims on all applicable lines of business to determine if additional information is needed and obtains the required information
• Claim Process Optimization- Adheres to the policy and procedures and assists in the development and implementation of new materials, guidelines, policies, and procedures
• Claim Resolution- Research and resolves claim issues by identifying and analyzing problems and/or risks, and assembling the documentation needed to support the recommendation to resolve the problem
• Alerting and Elevating Issues- Routes advanced issues to Director, Claims and Clinical, In House Nurses and/or Outside Vendor when certain risks are identified
• Reporting- Analyzes, summarizes, and reviews data; reports findings, interprets results and/or makes recommendations.
• Communication- Prepares written correspondence and other materials as needed for internal/external communications regarding claim status

Requirements

Education and Certifications

• Bachelor’s degree required
• Industry designations preferred

Experience

• Knowledge of current state issues, regulations, and industry trends as it relates to claims required
• Demonstrate proficiency with computer software including Microsoft Office Suite, with advanced skills in Excel required. Knowledge of Microsoft Access is beneficial, but not required
• Knowledge of COB (Coordination of Benefits), Medicare, HIPPA, CPT/HCPC, ICD-9/10, COBRA, and benefit plan interpretation preferred
• Knowledge of medical insurance stop-loss contracts, excess of loss-reinsurance, and self-funded plans preferred
• Understanding and experience with data analytics preferred
• Excellent verbal and written communication skills.
• Experience handling large volumes of stop loss claims preferred

Travel

• Some travel required.