Claims Examiner I

Job Description

Job Description

Beyond Health Partners, LLC , a Beyond Risk affiliate company , is looking for a motivated Claims Examiner I to join our growing stop loss claims team! This is a great opportunity for someone with early claims experience who enjoys digging into details, solving problems, and learning the ins and outs of medical stop loss insurance.

In this role, you will help review claim submissions, verify important documentation, communicate with internal and external partners, and support timely and accurate claim reimbursements. You will work closely with experienced claims professionals who can help you build your technical knowledge, strengthen your judgment, and grow within a collaborative team environment.

What You’ll Do:

1. Review stop loss claims: Process employer stop loss insurance claims for multiple carrier partners while following established carrier procedures, company guidelines, and applicable regulatory requirements.

1. Support accurate reimbursement decisions: Review claim submissions for completeness, accuracy, eligibility, coverage, and alignment with the plan document and stop loss policy.
2. Learn the details behind each claim: Audit documentation, identify missing information, recognize potential cost containment opportunities, and request additional details when needed.
3. Communicate with key partners: Work professionally with TPAs, producers, healthcare providers, vendors, carrier partners, and internal team members to keep claims moving forward.
4. Keep clear claim records: Maintain organized documentation of claim activity, correspondence, payments, case reserves, decisions, and resolutions in accordance with company standards.
5. Assist with case reserve management: Help set and monitor case reserves for assigned claimants, research medical conditions and treatment plans, and document reserve rationale with support from management.
6. Contribute to quality and accuracy: Perform quality checks to help ensure claims are processed accurately and consistently.
7. Look for ways to improve: Share ideas that may improve claim workflows, documentation, efficiency, or the overall claims experience.
8. Follow compliance requirements: Apply relevant policies, procedures, and regulatory guidelines while learning how compliance supports strong claim outcomes.
9. Pitch in where needed: Assist with logging new claim submissions, notifications, claims reporting, cross-training opportunities, high-volume periods, and special projects assigned by management.

What We’re Looking For:

• Bachelor’s degree in a related field or equivalent work experience.
• At least two years of property, casualty, medical, or other claims-related experience preferred.
• Strong attention to detail and an interest in reviewing documentation, data, and policy information accurately.
• Curiosity and willingness to learn medical stop loss insurance, plan documents, reimbursement processes, and case reserve concepts.
• Clear written and verbal communication skills with the ability to interact professionally with internal and external partners.
• Comfort using claims management systems, Microsoft Office Suite, and other business applications.
• Ability to work both independently and as part of a team in a deadline-driven environment.
• Willingness to obtain a MA A&H Producer license within the first three months of employment.
• Candidate must be local to the Beverly, Massachusetts area, as this role is required to be in the office five days per week upon hire. After three months of employment, there is potential for a hybrid schedule, at management’s discretion, with no less than three days in the office per week.

We are proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, national origin, ancestry, gender, gender identity and/or expression, genetic information, veteran status, disability, citizenship status, marital status, pregnancy, or any other characteristic protected by federal, state, or local employment discrimination laws.