Stop Loss Claims Specialist I-Specific

Role Description

The Stop Loss Claim Specialist is responsible for preparing and filing medical stop loss claims for reimbursement with stop loss carriers for individual stop loss (specific) coverage. Additional duties include following up with the various carriers to ensure reimbursements are received in time and in full. Further responsibilities include the appeals of denied and reduced claim reimbursements, along with retaining the appropriate documentation needed to support the reimbursement request.

Essential Functions

• Compile and submit claim reports and the necessary documentation to file a stop loss claim.
• Frequently monitor the status of claims assigned and follow up with stop loss carriers.
• Strong ability to answer questions and requests from stop loss carriers for additional information promptly and with thorough information in support of claim reimbursement.
• Communicate with other internal departments to resolve claim issues.
• Prepare both the initial, subsequent, and year end claim filings upon reconciliation of the claim activity.
• Ability to manage time to file advanced funding, high dollar and renewal claim submissions per contract stipulations and department metrics.
• Appeal the denials or reduction of reimbursements by the stop loss carrier.
• Understand stop loss policy provisions, as well as group plan documentation in support of claim reimbursements.
• Ability to adapt to new concepts and systems.
• Other duties as assigned.

Qualifications

• High School diploma or equivalent required.
• Some college or equivalent work experience preferred.
• 1 to 2 years of claims experience in a self funded environment.
• Thorough knowledge of Stop Loss terminologies, concepts, and catastrophic claim handling.
• Ability to interpret Stop Loss contracts and Client summary Plan Descriptions (SPD).
• Stop loss filing experience preferred.
• Accounting or Finance background a plus.
• Proficient with Microsoft Office Suite, specifically with Microsoft Excel.
• Strong analytical and problem solving skills.
• Excellent verbal and written communication skills.
• Demonstrated elevated level of organizational skills and superior attention to detail.
• Excellent time management skills with a proven ability to meet deadlines.
• Demonstrated ability in developing and maintaining positive relationships with team members, internal departments, various brokers, reinsurance carriers, and clients.

Position Competencies

• Accountability
• Communication
• Customer Service Orientation
• Functional/Technical Skills
• Quality Focus
• Time and Task Management

Physical Demands

This is a standard desk role requiring extended sitting and computer work.

Work Environment

Remote

Benefits

• Medical, Dental, Vision, Life and Disability Insurance
• Generous Paid Time Off
• Tuition Reimbursement
• EAP
• Technology Stipend