Senior Claims Analyst - Stop Loss

Company : Highmark Inc. Job Summary Are you ready to make a significant impact in the world of health insurance? As a Senior Claims Analyst specializing in Stop Loss claims, you will play a crucial role in reviewing, evaluating, and processing Excess Risk and Reinsurance claims. You'll work to establish strong client relationships, educate clients, and analyze claim losses while ensuring compliance with industry standards. This is a fantastic opportunity for individuals looking to leverage their expertise in health insurance to improve operations and client satisfaction. Essential Responsibilities Process daily Stop Loss claims with precision, offering guidance to clients and improving client service programs. Evaluate claims from Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) ensuring compliance with policy provisions and regulations. Monitor and analyze complex potential claims, utilizing a departmental checklist to verify eligibility and auditing claims for accuracy. Adjudicate or pend claims according to organizational policies, communicating effectively with TPAs, brokers, or customers regarding incomplete submissions. Identify discrepancies in claims and collaborate with the Special Investigation Unit as needed, while also aiding in internal training and process improvement. Assist in client performance evaluations, ensuring that client reports are accurate and operational efficiency is maintained. Approve claim payments for multiple clients, enhancing client counseling and support, and revising procedures for better client satisfaction. Maintain accurate and organized claim records. Perform additional duties as assigned. Education Required High School Diploma/GED Preferred Bachelor's degree Experience Required 5 years of experience in health insurance claims 3 years processing first dollar health insurance claims 3 years knowledge of medical terminology Preferred 3 years as a Stop Loss Claims Analyst. Skills Strong communication skills for providing clear and accurate information. Excellent organizational abilities. Effective time management skills. Capability to work independently. Strong problem-solving and analytical skills. Travel Requirement 0% - 25% This position is office-based. You may be requested to teach or train others occasionally. While physical tasks may be required, you will not be required to lift more than 25 pounds very often. Disclaimer This job description is designed to outline the general nature and essential duties of the position and may not list every responsibility or qualification needed. Compliance Requirement Adhere to ethical standards and company policies at all times. Please consider applying if you meet the qualifications for this exciting opportunity to enhance the health insurance landscape! #J-18808-Ljbffr Broughton Group