Senior Stop Loss Claims Analyst

Job Summary This job reviews, evaluates, and processes various Stop Loss (Excess Risk and Reinsurance) claims in accordance with established turnaround and quality standards. Responsible for building positive client relationships, providing education, and analyzing client claim losses as well as current issues regarding client activities; disseminates necessary information to management. Follows up on pended claims in accordance with department standards. Essential Responsibilities Processes daily incoming Stop Loss claims including initial entry claims or subsequent claims as needed; provides counseling to clients and assists with client service programs. Evaluates various claims submitted by Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) on behalf of self-funded clients for compliance with the following: underlying policy provisions, federal and state regulatory guidelines, and industry standards. Monitors, reviews and analyzes various complex potential claims with emphasis on controlling losses through effective managed care. This includes following a departmental claim checklist to ensure eligibility is met, the payment reimbursement request is accurate by auditing the claim for duplicate line‑item charges and determining if all information is available to finalize the payment request. Refers the claim to the cost containment and RxOps departments for review of high dollar charges if applicable. Determines whether to pend or adjudicate claims following organizational policies and procedures; finalizes and adjudicates claims up to pre‑determined dollar threshold. Completes pended claim letters for incomplete, invalid, or missing claim information to TPAs, brokers, or customers utilizing the appropriate application and/or template. Identifies potential discrepancies in claim submissions and involves the Special Investigation Unit as necessary. Identifies issues which can be used to educate/train internal staff, streamline, and improve processes and update documentation. Assists leadership with performing client performance evaluations to assess the accuracy of client reports submitted to the organization, efficiency of claim operations, and adequacy of systems and procedures. Approves claim payments on behalf of multiple clients and provides client counseling and support services. Assists in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with the organization. Maintains accurate claim records. Other duties as assigned or requested. Education Required High School Diploma/GED Substitutions None Preferred Bachelor’s degree Experience Required 5 years of relevant, progressive experience in health insurance claims 3 years of prior experience processing 1st dollar health insurance claims 3 years of experience with medical terminology Preferred 3 years of experience in a Stop Loss Claims Analyst role. Skills Ability to communicate concise accurate information effectively. Organizational skills Ability to manage time effectively. Ability to work independently. Problem Solving and analytical skills. Language (Other than English) None Travel Requirement 0% - 25% Physical, Mental Demands and Working Conditions Position Type: Office‑based Teaches / trains others regularly: Occasionally Travel regularly from the office to various work sites or from site‑to‑site: Rarely Works primarily out‑of‑the office selling products/services (sales employees): Never Physical work site required: Yes Lifting: up to 10 pounds - Constantly Lifting: 10 to 25 pounds - Occasionally Lifting: 25 to 50 pounds - Rarely Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum $23.16 Pay Range Maximum $35.88 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. EEO Statement Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. #J-18808-Ljbffr