Stop Loss Claims Specialist

Description:

Allied is excited to announce that we are looking for a Stop Loss Claims Specialist to join our team! This person will be responsible for identifying, tracking, reviewing, and processing stop-loss reimbursements claims on behalf of carriers within an MGU stop-loss operation. An ideal candidate brings strong knowledge of medical claims, stop-loss policy interpretation, and large-claim management in a self-funded or TPA environment.

Duties/Responsibilities

Review and process specific and aggregate stop-loss claims in accordance with policy provisions, carrier guidelines, and internal procedures

Interpret stop-loss contracts and supporting plan documents to determine reimbursement eligibility, required documentation, and claim disposition

Monitor high-cost and ongoing claims for reimbursement potential and follow up on outstanding submissions or requests for additional information

Prepare, track, and report specific and aggregate claim activity, including aggregate accommodation calculations, monthly reporting, and audit support

Analyze claims, medical documentation, and supplemental materials to ensure timely, accurate claim handling and clear audit trails

• Must have a high school diploma or equivalent. Associate or Bachelors in a related field is a plus.
• Needs to have 3+ years of experience in medical claims processing, stop-loss administration, aggregate claim review and processing, large claim review, or a related self-funded environment
• Must be able to read, interpret, and apply stop-loss contracts, policy language, and supporting plan documents

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