Medical Stop Loss Claims Auditor

Job Description

Job Description

Stop Loss Claims Auditor or Senior Stop Loss Claims Auditor

The Stop Loss Auditor is responsible for auditing and authorizing reimbursements of specific claims and effectively mitigate client medical stop loss claims and provide excellent customer service.

Experience/Qualifications:

• 3-5+ years of experience in auditing medical Stop Loss Claims.
• Audit stop loss claims and verify claims are paid in accordance with the Plan Document and reimbursable under the stop loss contract.
• Timely follow-up of pending claims to ensure additional information is received.
• Recognize cost mitigation opportunities.
• Interpret plan languages and stop loss contracts.
• Familiar with the process of referring claims for over-authority review and approval to the carrier.
• Efficient communication with both internal and external customers
• Experience with auditing aggregate claims
• Captive experience a plus
• Ability to analyze claims and/or large claim management reports to post and/or adjust reserves.

Skills/Abilities

• 2-3 years medical claim processing or 3-5+ years Stop Loss Claims Auditing and reinsurance experience.
• Bachelor’s degree a plus.
• Experience TPA Claims Processing and cost mitigation.
• Proficient in Excel (for example: sorting, filtering, data, creating pivot tables.)
• Ability to interpret and understand Plan Document wording and the application of provisions including eligibility.
• Knowledge in COB, Medicare rules, CPT codes, REV codes, ICD-10 codes, HCPCS codes, J-codes
• Excellent customer service, organizational with strong analytical skills
• Detail/results-oriented
• Ability to work independently with minimal supervision while meeting or exceeding established production and accuracy standards.
• Ability to interpret and understand Stop Loss Contracts
• Customer Service focused.
• Excellent verbal and written communication skills

What We Offer:

We're proud to offer a competitive salary, generous and flexible PTO & paid holidays, 401(k) with match, exclusive discount programs, health & wellness programs, and more.

Benefits:

• Health insurance
• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health savings account
• Life insurance
• Vision insurance

About Evolution Risk Partners, LLC

Evolution Risk Partners (ERP) is a full service Managing General Underwriter redefines partnership through a shared vision of success with employers and brokers. We provide organizations with customizable and innovative medical stop-loss solutions to ensure the financial stability of your self-funded medical program. Interested parties should visit