Stop Loss Claims Analyst

Position Overview:

The Claims Analyst is responsible for providing assistance to the Claims Manager while ensuring that claims are properly adjudicated in accordance with our Policy and the underlying Plan/Group Documents.

This position will report to the Claims Manager.

Essential Elements

• Review, analyze, manage, and adjudicate claims on the Stop Loss and Excess of Loss book of business to determine action to be taken.
• Research and resolve claim issues by identifying and analyzing problems and/or risks, and assembling the documentation needed to support the recommendation to resolve the problem.
• Maintain applicable logs, files, and company turnaround time standards.
• Maintain knowledge of the insurance industry through continuing education.
• Other tasks as assigned.

Requirements:

Education and Certifications:

• Bachelor’s degree or commensurate experience required
• Insurance 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 COB, Medicare, HIPPA, CPT, ICD-10, COBRA, and benefit plan interpretation preferred
• Knowledge of medical insurance stop-loss contracts and self-funded plans preferred
• Understanding and experience with data analytics preferred
• Experience handling large volumes of stop loss claims preferred
• Understanding and experience with data analytics preferred

Travel:

• Limited travel to Third Party Administrator (TPA) sites.