Claims Examiner-Stop Loss Coord.

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The Claims Examiner and Stop Loss Coordinator is responsible for reviewing and processing professional and hospital claims for Community Care Health (CCH) in-network and out-of-network providers. This role will review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorization, and process them for payment. Tracks potential and existing stop loss members, timely filing of all stop loss claims with the carrier, follow-up with the carrier regarding outstanding recoveries, and reporting. Provides overall assurance that CCH is in compliance with the stop loss policy.

1. Analyzes and adjudicates various claim types to include Inpatient/Outpatient facilities and professional services within the individual threshold limit.

2. Evaluates claims and determines payment or denial according to plan provisions, medical policies, and department guidelines.

3. Assures that all claims are adjudicated in accordance with CMS and DMHC rules and claim timeliness regulations.

4. Works with internal departments (e.g., Customer Service, Eligibility, etc.) for additional claim information and reinsurance carriers for claims related to Stop Loss.

5. Coordinates claims with primary and secondary insurance as needed and policy year-end claims to ensure payments within the stop loss contractual period.

6. Researches and determines proper CPT Procedure and ICD-10 Diagnosis Codes to bill with claims.

7. Processes high dollar claims (e.g., inpatient, outpatient, transplant, etc.), voided checks, refund checks, appeals, provider disputes, and adjustments.

8. Participates in the Health Industry Collaboration Effort (HICE) Claims Standardization Team’s monthly calls.

9. Monitors specific and aggregate medical/pharmacy claims and notifies the reinsurance carrier of pertinent information.

10. Files all stop loss claims with the reinsurance carrier in a timely manner to obtain maximum reimbursement.

11. Generates stop loss reports for internal usage and for submission to the reinsurance carrier and broker.

12. Enters and maintains reinsurance information. Follows up with the reinsurance carrier regarding outstanding recoveries.

13. Performs other job-related duties as assigned.